Liver Transplantation for Hepatic Graft-Versus-Host-Disease: A United Network for Organ Sharing (UNOS) Database Study

Liver Transplantation for Hepatic Graft-Versus-Host-Disease: A United Network for Organ Sharing (UNOS) Database Study

Background: Liver graft-versus-host-disease (GVHD) after hematopoietic stem cell transplantation (HSCT) is uniformly fatal once it becomes steroid-refractory. No FDA-approved treatments exist for this condition and majority of the clinical trials in GVHD treatment paradigm have focused on the general treatment of acute GVHD as a whole rather than organ specific treatment. Case reports and case series of orthotopic liver transplantation (OLT) for hepatic GVHD have been published with varying results. Herein, we present the analysis from a large national database on the outcomes of OLT in hepatic GVHD. 

Methods: A United Network for Organ Sharing (UNOS) database review of all OLTs between 1998 and 2012 was performed*. Rejection, transplant list registration, blood group type, indications, waiting time, MELD score and other relevant variables for both HSCT and OLT were obtained and analyzed for clinical outcomes, using the Cox proportional hazards model. Survival after OLT performed for GVHD was compared to OLT performed for non-GVHD indications.

Results: 112 OLTs were reported by UNOS for GVHD. N was 94 for the final sample for analysis given the criteria used for inclusion in the study. Among these, 46 had hepatic GVHD secondary to renal or intestinal transplantation, and 48 following HSCT. Median survival for HSCT-GVHD patients was 8.5 years. 1, 3 and 5 year survival of the HSCT-GVHD patients were 0.69, 0.64 and 0.59, respectively.  ABO grouping, age, gender, and MELD score did not affect the patient survival in the HSCT-GVHD cohort. Survival analyses performed for OLT stratified by indication (GVHD vs no GVHD) [figure 1] indicate significant differences in outcome.

Conclusion:  OLT is an underutilized treatment modality for hepatic GVHD in HSCT patients. Although the survival after OLT for GVHD is inferior to that of OLT for non-GVHD indications , it is remarkably better than non-OLT strategies currently utilized for treatment of hepatic GVHD (5 year survival <10%, historic data).  Thus, OLT should be considered early in management of steroid refractory hepatic GVHD.

* “Based on OPTN data as of January 17, 2014; This work was supported in part by Health Resources and Services Administration contract 234-2005-37011C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government."

Survival post liver transplant for GVHD vs non-GVHD indication