Infliximab treatment for steroid-refractory acute graft-versus-host disease after orthotopic liver transplantation: A case report

Abstract

Acute graft-versus-host disease (GVHD) following orthotopic liver transplantation is a rare but severe disease with a 75% death rate in adults. Various therapeutic strategies have been proposed for steroid-refractory GVHD, but there is still no consensus. Tumor necrosis factor-alpha is a key inflammatory cytokine involved in acute GVHD physiopathology, and infliximab has shown encouraging results for the treatment of acute GVHD following hematopoietic stem cell transplantation. We report the first case of acute GVHD following liver transplantation that was refractory to steroids and anti-lymphocyte globulin but was successfully treated with infliximab. Liver Transpl 15:682–685, 2009. © 2009 AASLD.

Acute graft-versus-host disease (GVHD) following liver transplantation was first described in 1988 by Burdick et al.,1 and about 80 cases have been reported in the literature.2 Acute GVHD following liver transplantation is a rare but severe complication commonly associated with resistance to steroid therapy. There is no consensus to date for treating such steroid-refractory forms. Tumor necrosis factor-alpha (TNF-α) is a key inflammatory cytokine involved in the pathogenesis of GVHD, and infliximab, an anti–TNF-α antibody, has been used in acute GVHD following hematopoietic stem cell transplantation with encouraging results.3 Here we report the first experience to date with infliximab for GVHD following liver transplantation.

CASE REPORT

A 67-year-old Caucasian man with a history of treated hypertension and prostatic adenocarcinoma that had been successfully treated with radiotherapy 5 years ago underwent transplantation for Child-Pugh A hepatitis B virus–related cirrhosis associated with hepatocellular carcinoma in November 2004. The donor was a 61-year-old Caucasian male who had died of a stroke; he was seronegative for hepatitis B virus, hepatitis C virus, and cytomegalovirus (CMV) and had a normal liver according to a histological examination. The human leukocyte antigen (HLA) class of the donor, determined with serological methods, was HLA-A1, B7, B8, DR4, DR17, DQ2, and DQ 3, and the blood group was A rhesus–negative, whereas the HLA class of the recipient was HLA-A2, A68, B18, B39, DRB1*03, DRB1*11, DRB3*01, DRB3*03, DQB1*02, and DQB1*03, and his blood group was A rhesus–positive. A bacterial culture of the graft preservation fluid was positive for methicillin-resistant coagulase-negative Staphylococcus. The total ischemia time was 620 minutes. He received antibiotic prophylaxis, antiviral therapy (lamivudine plus adefovir dipivoxil), and passive antibody to hepatitis B surface antigen immunoprophylaxis according to Samuel et al.4 The immunosuppressive regimen included corticosteroids at the dosage of 300 mg/day on the first postoperative day with a rapid reduction and tacrolimus (at 0.1 mg/kg/day). In week 3, the patient developed a skin rash, which evolved toward desquamation in a few days. Forty-eight hours after the rash onset, his condition worsened, including fever (38.5°C), diarrhea, and confusion. The white blood cell count (<0.6 g/μL) showed leukopenia. Large antibiotic prophylaxis (against bacteria, CMV, and fungi) and granulocyte colony stimulating factor were started. Bacteriological examinations of blood, stool, urine, and cerebrospinal fluid were negative. The culture of peritoneal drainage was positive for the same Staphylococcus previously found, without any clinical sign of peritonitis. Skin biopsy showed basal cell layer vacuolization, necrosis of keratinocytes, leukocyte infiltration of the dermis without eosinophils, and no sign of CMV infection. The colonic mucosa was macroscopically normal and histologically showed crypt cell apoptosis without any sign of CMV infection. These features were suggestive for the diagnosis of grade 4 acute GVHD involving the skin and bowel. GVHD diagnosis was confirmed by the detection of a substantial proportion (8.9%) of donor CD3+ lymphocytes in the peripheral blood. Chimerism analysis was performed on peripheral blood nucleated cells. Percentages of donor-host chimerism for recipients were based on semiquantitative polymerase chain reaction (PCR)–based amplification of short tandem repeat sequences unique to the donors and hosts (AmpFlSTR Identifiler PCR amplification kit, Applied Biosystems).5 Genomic DNA was amplified with a multiplex PCR assay of 16 short tandem repeat sequences in accordance with the manufacturer's recommendations. An analysis of PCR products on a 3130 DNA analyzer using Genemapper software version 3.2 allowed discrimination of the recipient and donor profiles and identification of the percentage of chimerism. In week 3, intravenous methylprednisolone (two 1-g boluses and then 2 mg/kg/day) was thus started. In week 4, in the absence of clinical improvement, rabbit anti-thymocyte globulin (Genzyme Europe B.V., The Netherlands) was started at the dose of 2.5 mg/day for 2 consecutive days with maintenance of methylprednisolone. In week 7, the skin rash worsened to a generalized form. The methylprednisolone dose was thus increased to 3 mg/kg/day for 5 days, and this was combined with 3 weekly injections of 10 mg/kg intravenous infliximab. Forty-eight hours after the onset of infliximab therapy, we noted the disappearance of the skin rash. A third injection of 2.5 mg/kg anti-lymphocyte globulin was given in week 8. Sustained clinical remission was subsequently achieved, and this allowed steroid withdrawal. In week 10, the search for donor CD3+ lymphocyte chimerism in the peripheral blood was negative. Two months after liver transplantation, CMV-related hepatitis was diagnosed on the basis of cholestasis, an increase in the blood CMV DNA load (80,000 copies/mL as measured by PCR), and liver damage compatible with anti-E13–immunolabeling positivity in a liver biopsy specimen. It was successfully cured by a 3-week regimen of intravenous ganciclovir. A few weeks later, the patient developed Klebsiella oxytoca plus Clostridium difficile–related acute diarrhea, which was successfully treated with antibiotics. The patient was discharged home during month 5 post–liver transplantation. No significant event occurred during a 3-year follow-up period after liver transplantation: the patient's clinical status remained excellent.

CMV, cytomegalovirus; GVHD, graft-versus-host disease; HLA, human leukocyte antigen; HSCT, hematopoietic stem cell transplantation; PCR, polymerase chain reaction; TNF-α, tumor necrosis factor-alpha.

DISCUSSION

Acute GVHD is an uncommon complication of liver transplantation; its prevalence has been estimated to be 0.3 to 1.9%.2, 6-8 Acute GVHD usually occurs between weeks 1 and 8 after liver transplantation.9 The presentation includes skin rash, fever, nonbloody diarrhea, and pancytopenia. Acute GVHD following liver transplantation does not involve the liver because the lymphocytes involved in GVHD belong to the liver graft. In our center, only 4 cases of acute GVHD occurred in the 488 liver transplants performed between March 1986 and January 2008 (0.8%), and this was consistent with previously published rates. In the present case, the diagnosis of acute GVHD was assessed by the association of concordant clinical and biological criteria and the demonstration of chimerism in the blood. At the time of the GVHD diagnosis, donor CD3+ lymphocytes were detectable in the peripheral blood, constituting 8.9% of total lymphocytes. In a series of 7 cases of GVHD following liver transplantation, Taylor et al.8 found donor CD3+ lymphocyte levels ranging from 4% to 50%.8 Three risk factors for GVHD can be identified in our case report: recipient age greater than 65 years old,7 liver transplantation for hepatocellular carcinoma,6 and compromised immune status of the recipient before liver transplantation following prostatic and hepatic neoplasia and chronic hepatitis B.9

GVHD following liver transplantation is considered to be associated with poor prognosis. In our center, 3 of 4 patients who developed acute GVHD died between weeks 4 and 8 post–liver transplantation. These results are in keeping with the overall adult mortality rate of 75% found in the literature.2 However, the review of Perri et al.2 included isolated case reports with a good outcome. When only the series evaluating GVHD prevalence were pooled, 33 of 3907 patient undergoing liver transplantation developed acute GVHD with a mortality rate of 85%, and this emphasizes the urgent need for efficient therapies.

To the best of our knowledge, this is the first report of infliximab treatment for acute GVHD following liver transplantation. Although infliximab therapy was used in combination with anti-lymphocyte globulin, its efficiency in actually resolving GVHD is likely because previous use of anti-lymphocyte globulin (in combination with steroids or alone) was inefficient. Moreover, clinical recovery began 48 hours after the onset of infliximab therapy (1 week before the third infusion of anti-thymocyte globulin).

Infliximab is a chimerical mouse/human immunoglobulin G antibody directed against soluble and transmembrane forms of human TNF-α, and it is used for the treatment of rheumatoid arthritis,11 Crohn's disease,12 ulcerative colitis,13 and psoriasis.14 In 1992, our center reported for the first time the successful use of home-made monoclonal anti-TNF antibodies in refractory GVHD following hematopoietic stem cell transplantation (HSCT) in a pilot study that included 19 patients.15 Since then, various retrospective case series have found encouraging results with infliximab for the treatment of steroid-refractory acute GVHD following HSCT.3, 16–19 During acute GVHD, TNF-α is secreted by monocytes and macrophages, leading to donor T cell activation and inducing a cascade of inflammatory cytokine and cell activation and tissue damage.20 An early increase in TNF-α and TNF-α receptor plasma levels is associated with the development of acute GVHD.21, 22 The recovery of GVHD-induced bowel damage following infliximab has been clearly described in the setting of HSCT. This finding is similar to that observed in inflammatory bowel diseases12, 13 and raises the hypothesis of a specific role of TNF-α in cibling bowel damage.23 In the context of HSCT, another interesting finding is that the best responses to infliximab were achieved in patients whose GVHD did not involve the liver.3, 16–19 This suggests that infliximab could be particularly interesting for GVHD following liver transplantation.

To date, the best regimen of infliximab therapy is not known. In the present case, a rapid and complete remission of acute GVHD was observed with the administration of 3 perfusions of 10 mg/kg infliximab within 1 week. This regimen used the same cumulative dose but a shorter duration than previously described: in the majority of case series reporting the use of infliximab for acute GVHD following HSCT, a 10 mg/kg/week infliximab regimen was administered for a median duration of 3 weeks.3, 16–19 Because the patient had a life-threatening relapse after 2 perfusions of anti-thymocyte globulin and an increase in steroids, and in order to limit the total dose of anti-thymocyte globulin to 7.5 mg/kg in a patient with a history of cancer, we decided to use a reinforced regimen of infliximab therapy. The rapid response observed in the 48 hours following the onset of infliximab therapy encouraged us to rapidly repeat infliximab perfusions. However, although successful in the present case, such an intensive infliximab regimen should not be considered validated, and the best infliximab regimen for this indication warrants further investigation. Another unresolved issue is the role of infliximab with respect to other immunosuppressive therapies. In the present case, we used infliximab as a third-line treatment after steroids and anti-lymphocyte globulin had failed. Some authors estimate that infliximab should be introduced early after the diagnosis of steroid-refractory acute GVHD.17 The rationale for using infliximab as a second-line therapy is that this strategy may reduce the duration of heavy immunosuppression and thereby reduce the risk of infection, a leading cause of death following GVHD.2 Moreover, by avoiding the use of anti-thymocyte globulin, we could expect a lower risk of subsequent lymphoproliferative disorders.24 However, the use of infliximab does not guarantee the absence of infections or cancers. Our patient developed both bacterial and viral infections, as frequently described in the literature. The risk of de novo cancer following infliximab therapy warrants further long-term studies.25

Finally, this report highlights the need for early recognition of acute GVHD following liver transplantation, which may favor a favorable outcome. For this purpose, early bone marrow examinations of symptomatic patients and the systematic detection of lymphocyte chimerism could be 2 useful tools. Domiati-Saad et al.26 showed that the pattern of lymphocyte chimerism following liver transplantation is a rapid decrease over time.26 Interestingly, the cutoff of 20% of the donor CD3+ T cell levels in the peripheral blood measured at least 1 week after liver transplantation was predictive of subsequent GVHD.

In conclusion, acute GVHD following liver transplantation is a rare but frequently lethal complication. A consensus for the treatment of steroid-refractory forms is lacking. Because TNF-α is a key cytokine involved in acute GVHD, infliximab could be efficient for GVHD following liver transplantation, as previously shown in GVHD following HSCT, particularly in patients with bowel and skin lesions without hepatic damage. We documented for the first time a complete response and long-term remission of steroid-refractory acute GVHD following liver transplantation after the use of infliximab therapy. Further studies are needed to evaluate infliximab efficiency and tolerance and to identify the best infliximab regimen for GVHD following liver transplantation.

Acknowledgements

The authors thank Mrs. Frances Mary Sheppard from the Centre d'Investigation Clinique of Besançon for her assistance in drafting the article.