Bone Marrow Transplantation (2004) 34, 57–61 & 2004 Nature Publishing Group All rights reserved 0268-3369/04 $30.00
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Graft-versus-host disease Liver graft-versus-host disease after donor lymphocyte infusion for relapses of hematologic malignancies post allogeneic hematopoietic stem cell transplantation SY Ma1, WY Au1, AKW Lie1, I OL Ng2, AYH Leung1, EW Tse1, RH Liang1, GK Lau1 and YL Kwong1 1
Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong; and 2Department of Pathology, University of Hong Kong, Queen Mary Hospital, Hong Kong
Summary: Graft-versus-host disease (GVHD) is the commonest complication after donor lymphocyte infusion (DLI). In 19 patients undergoing DLI for relapses of hematologic malignancies post hematopoietic stem cell transplantation (HSCT), 11 developed GVHD, of whom nine had isolated liver involvement, and two had liver and skin involvement. The clinical diagnosis of liver GVHD was hepatitic in six patients (55%) and classical in five patients (45%). Patients with GVHD post-DLI showed a different clinical pattern when compared to a cohort of 106 cases of GVHD post-HSCT, in having significantly more isolated liver involvement (9/11 vs 17/106, Po0.001), and less skin (2/11 vs 80/106, Po0.001) and gut (0/11 vs 28/106, Po0.001) involvement. However, liver GVHD post-DLI and post-HSCT had comparable patient characteristics, underlying diseases, clinical subtypes (classical and hepatitic) and response to treatment. Bone Marrow Transplantation (2004) 34, 57–61. doi:10.1038/sj.bmt.1704522 Published online 24 May 2004 Keywords: liver GVHD; DLI; HSCT
Donor lymphocyte infusion (DLI) is an important treatment for hematologic malignancies relapsing after allogeneic hematopoietic stem cell transplantation (HSCT).1 Currently, DLI is used in post-HSCT relapses in many hematologic malignancies, with chronic myeloid leukemia (CML) showing the best response,2,3 followed by multiple myeloma4,5 and acute myeloid leukemia.2 The commonest complication after DLI is graft-versushost disease (GVHD), occurring in 20–60% of patients.1,5–7 The best predictor for GVHD post-DLI is a high T-cell dose.6–8 Few studies have compared the pattern of GVHD
Correspondence: Dr YL Kwong, University Department of Medicine, Professorial Block, Queen Mary Hospital, Pokfulam Road, Hong Kong; E-mail:
[email protected] Received 10 November 2003; accepted 22 January 2004 Published online 24 May 2004
after HSCT with post-DLI. Recently, a hepatitic variant of liver GVHD9 has been found to be more prevalent after DLI, which is apparently associated with a poor response to treatment and prognosis.10 In this study, we evaluated 19 patients treated with DLI for leukemic relapses post-HSCT, and analyzed the patterns and treatment outcome of liver GVHD in these patients.
Materials and methods Patients The records of patients undergoing DLI between January 1996 and June 2002 at the Department of Medicine, Queen Mary Hospital, were reviewed. Patients with CML in molecular/cytogenetic relapse, whose blood group was compatible with the donor, were given 1 U of blood venesected from the donor as DLI. For all other patients, as well as CML patients not responding to the first infusion, mononuclear cells (MNC) were collected from donors by processing 7 L of blood through cytapheresis equipment (CS-3000 Plus, Baxter, Deerfield, IL, USA), and were infused directly into the patients. There was no specific target MNC count for each infusion. Depending on the response, patients might receive one or more additional MNC infusions on a weekly basis. The total cellular dose was defined as the cumulative MNC dose/kg transfused.
Clinical and laboratory evaluation A thorough physical examination was performed and investigations were carried out.11 In patients with impaired liver function tests (LFT), potential viral causes of hepatitis were investigated with the following laboratory tests: hepatitis B surface antigen (HBsAg) (microparticle enzyme immunoassays, Abbott Laboratories, Chicago, IL, USA), anti-hepatitis C virus (HCV) antibody (enzyme immunoassays EIA-3, Abbott Laboratories), cytomegalovirus (CMV)-DNA in white blood cells by polymerase chain reaction (PCR) and standard serological tests for herpes simplex virus and varicellar zoster virus infection. The highest value of bilirubin, alkaline phosphatase (ALP), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were recorded and analyzed. GVHD affecting
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other organs were recorded and graded according to standard criteria.12
Results Patients
Study design and definition Biochemical parameters were used to classify liver GVHD into the classical type, defined as elevation of bilirubin and ALP, with AST and ALT less than 10 times normal, and the hepatitic type, defined as elevated bilirubin and ALP, with AST and/or ALT more than ten times normal.9,10 To investigate if liver GVHD post-DLI and post-HSCT might be different, patients undergoing HSCT and developing GVHD within the same study period were used for comparison.13
A total of 19 adult patients received DLI for relapses of hematologic malignancies post-HSCT (Table 1). None of these HSCT was T-cell depleted. Chemotherapy was not given before DLI. DLI was given at a median of 797 (294–2053) days post-HSCT. Six patients received one infusion, nine patients two infusions and four had three or more infusions. The median total dosage of MNC infused was 6.16 108 (3.66 107 – 6.68 108/kg). HBsAg was positive in only one patient. No patient was positive for anti-HCV. A total of 11 patients developed GVHD at a median of 66 (22–138) days post-DLI. Nine patients had isolated liver GVHD, and two had liver and skin GVHD.
Statistical analysis Difference between groups was analyzed by t-test for continuous data and the w2 test or Mann–Whitney test for categorical data (SPSS statistical program, version 10.0). A P-value of less than 0.05 was considered to represent a statistically significant difference. Table 1
Clinical correlations of liver GVHD post-DLI The clinicopathologic features of patients with and without liver GVHD post-DLI are shown in Table 1. None of the parameters examined, including sex, age, underlying disease,
Clinicopathologic features of 19 patients with or without liver GVHD after donor lymphocyte infusion (DLI)
Features
Male Female Mean age (range) years
Liver GVHD after DLI Present (n ¼ 11)
Absent (n ¼ 8)
P-value
7 4 35 (17–46)
3 5 33 (20–41)
NS
8 2 1
7 0 1
NS
7 4
8 0
NS
8 2 1
7 1 0
NS
6 2 2 1 1128 (490–2053) 0
7 0 0 1 889 (294–1546) 1
NS
4 7
1 7
NS
4 7 2.4 10 (0.36–6.16 108)
5 3 2.1 10 (0.58–6.68 108)
NS
6 5
3 5
NS
At initial HSCT Underlying disease Chronic myeloid leukemia Myeloma Acute leukemia Disease stage CR1 or CP1 Advanced Donor HLA identical sibling One HLA mismatch sibling Matched unrelated At relapse Chronic myeloid leukemia Cytogenetic/molecular relapse Accelerated/blastic phase Myeloma Acute leukemia in molecular relapse Time from HSCT to DLI (days) HBsAg positive GVHD during previous HSCT Yes No Total MNC infused o 108/kg 4 108/kg Mean cumulative dose (per kg) Disease response after DLI Complete response Partial or no response
8
8
NS
NS
NS
HSCT ¼ hematopoietic stem cell transplant; DLI ¼ donor lymphocyte infusion; GVHD ¼ graft-versus-host disease; CR1 ¼ first complete remission; CP1 ¼ first chronic phase; HLA ¼ human leucocyte antigen; HBsAg ¼ hepatitis B surface antigen; MNC ¼ mononuclear cell; NS ¼ statistically not significant.
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types of donor, timing and indications of DLI, pre-existing GVHD, total cell dose infused and the disease response, were related to the development of liver GVHD post-DLI.
whether liver GVHD post-DLI differed from that postHSCT, their clinicopathologic features were compared (Table 2). The two groups differed significantly in the patterns of GVHD. Liver GVHD post-DLI compared to post-HSCT showed more frequent isolated hepatic involvement (9/11 vs 17/106, Po0.001), less concomitant skin involvement (2/11 vs 80/106, Po0.001), and no gut involvement (0/11 vs 28/106, Po0.001). At the onset of GVHD, liver GVHD post-DLI
Comparison of liver GVHD post-DLI and post-HSCT During the same period, 320 adults underwent allogeneic HSCT, of whom 106 developed liver GVHD.13 To assess
Table 2
Clinicopathologic features and treatment outcome of liver GVHD in 11 post-DLI patients and 106 post-HSCT patients
Characteristics
Liver GVHD Post-DLI (n ¼ 11)
Post-HSCT (n ¼ 106)
P-value
7/4 35 (17–46)
62/44 35 (17–53)
NS NS
Donor HLA full matched One HLA antigen mismatch Matched Unrelated donor
8 (73%) 2 (22%) 1 (5%)
78 (74%) 6 (6%) 22 (20%)
NS
Underlying disease Acute Leukemia Chronic myeloid leukemia Lymphoma/myeloma
1 (5%) 8 (73%) 2 (22%)
69 (65%) 22 (20%) 16 (15%)
ND
Disease status at HSCT CR1 / CP1 Advanced
7 (64%) 4 (36%)
64 (60%) 42 (40%)
ND
GVHD Skin involvement Gut involvement Isolated liver involvement Liver biopsy performed
2 (18%) 0 9 (82%) 0
80 28 17 43
Male/female Mean age, years (range)
Mean peak LFT Bilirubin ALP ALT AST
42 302 245 356
Liver GVHD subtype Classical Hepatitic Mean timing of events, days Onset of LFT derangement after HSCT/DLI Time to peak LFT from onset Treatment Cyclosporine Number of patients requiring treatment Mean cumulative dosea, mg (range) Prednisolone Number of patients requiring treatment Mean cumulative dosea, mg (range)
(7–263) (95–1100) (56–512) (98–694)
5 (45%) 6 (55%)
107 (7–409) 33 (0–209)
3 (27%) 4983 (2100–9000) 6 (55%) 732 (210–1500)
Treatment outcome Number of patients with resolution of liver GVHD Duration of peak to normal LFT, days Chronic GVHD Death from GVHD
10 (91%) 92 (11–267) 0 1 (9%)
130 302 228 307
(75%) (26%) (16%) (41%)
(7–1820) (55–1204) (22–1277) (1–1290)
o0.001 o0.001 o0.001 o0.001
0.015 NS NS NS
68 (64%) 38 (36%)
NS NS
69 (22–138) 21 (0–97)
NS NS
99 (93%) 12020 (200–81250)
o0.001 0.047
67 (63%) 2277 (50–16100)
NS o0.001
88 75 5 13
(83%) (3–432) (5%) (12%)
NS NS NS NS
CR ¼ complete remission; CP1 ¼ first chronic phase; FK506 ¼ tacrolimus. a Total dose of drugs used from derangement to normalization of LFT.
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and post-HSCT did not differ in bilirubin, AST, ALT and ALP. However, at peak LFT derangement, liver GVHD postDLI showed a lower bilirubin level than that post-HSCT (42 vs 130 mmol/l, P ¼ 0.015). Otherwise, the two groups were comparable with respect to demographic features, underlying diseases, patterns of LFT derangement, clinical types (hepatitic or classical) of liver GVHD and the duration of LFT impairment.
Treatment outcome of liver GVHD after DLI and HSCT Patients were treated with cyclosporine and steroid-based immunosuppressive regimens, with azathioprine and mycophenolate mofetil added at the discretion of the attending physicians. Cyclosporine was used in fewer patients and at a lesser cumulative dose in patients post-DLI, but this might reflect a more conservative approach of the attending physicians in treating GVHD, in an attempt to maximize the putative graft-versus-disease effect. The same reason might account for the use of prednisolone at a lower cumulative dose. However, resolution of liver GVHD was comparable in both groups (10/11 vs 88/106, P ¼ not significant). The time for onset, peaking and resolution of LFT derangement was also comparable in the two groups (107 vs 69 days, 33 vs 21 days and 92 vs 75 days, respectively, P ¼ not significant). LFTs returned to normal in all patients post-DLI, but remained abnormal although improved in five post-HSCT patients. A total of one (9%) patient in the post-DLI group and 13 (12%) patients in the post-HSCT group died of GVHD.
Discussion GVHD is one of the major causes of morbidity and mortality after HSCT and DLI. GVHD of the skin and gut is clinically evident and easily confirmed. However, the diagnosis of GVHD of the liver may be problematic, as other confounding factors including viral hepatitis, and liver injury related to drugs, treatment regimen and sepsis are often present.14–16 The problem is accentuated post-DLI, as the pattern and prognosis of liver GVHD in this setting are not clearly delineated. Although liver biopsy is helpful in diagnosis, it is not entirely safe, particularly with low platelet counts. Even with the use of transjugular liver biopsy, the rate of complications has ranged from 1.3 to 20.2%, with a consequent mortality of 0.1–0.5%.17,18 Therefore, liver GVHD is often diagnosed on clinical grounds, relying traditionally on the presence of cholestatic LFT derangement with marked elevation of bilirubin and ALP as sensitive markers.19,20 However, with the recent description of a hepatitic type of GVHD after both HSCT9 and DLI,10 the diagnostic algorithm of LFT derangement becomes complicated, as patients with predominantly hepatitic changes may also have to be evaluated for GVHD. In this study, 11/19 patients (58%) had clinical evidence of GVHD post-DLI, a frequency that was comparable with previous studies.2,7 Interestingly, all of these cases showed LFT derangement, with only two cases showing concomitant skin involvement. A limitation of this study is the absence of liver biopsy for confirmation of GVHD. Bone Marrow Transplantation
However, we had excluded other possible etiologies, including drugs and known viral infections. Furthermore, we have shown previously that, in the absence of a suspicion of hepatitis B and C infection, the clinical diagnosis of GVHD correlated well with histopathologic findings.11 Finally, successful treatment with immunosuppression strongly suggested that the LFT derangement was due to GVHD. Predominant liver involvement in GVHD post-DLI has not been reported before. De Lima et al21 reported that of eight patients developing GVHD postDLI, all had skin and gut involvement, but only two had liver involvement. Marks et al 22 reported that of 27 patients with GVHD post-DLI, skin involvement was the commonest (78%), followed by gut (41%) and liver (26%). In these studies, it was uncertain if hepatitic LFT derangements were also considered as a form of liver GVHD, which might have affected the relative frequency of liver GVHD as compared to skin and gut GVHD. Finally, when our 11 patients with liver GVHD post-DLI were compared with the 106 patients with liver GVHD post-HSCT, they were similar in practically all clinical and biochemical aspects. However, an interesting difference was the preponderance of liver GVHD and the apparent absence of concomitant gut involvement post-DLI. These results suggested that the pathogenetic mechanisms or effector cells of liver GVHD post-DLI might be different from those post-HSCT. However, it must be noted that in HSCT, chemoirradiation is used in conditioning, and GVHD prophylaxis is also administered; neither of which are given with DLI. Furthermore, CML patients constituted more than 70% in the DLI group as compared with about 20% in the HSCT group. Finally, GVHD post-HSCT usually occurs in the setting of continued administration of immunosuppression, and the possible existence of residual toxicity from the preceding conditioning regimen; both of these are absent in patients receiving DLI. These factors might also have contributed to the different patterns of GVHD. Recently, Akpek et al10 reported 22 cases of liver GVHD post-DLI, with 11 cases (50%) being classified as hepatitic GVHD. They reported a poor overall prognosis for hepatitic GVHD, with about 60% showing progression despite high-dose combination immunosuppression, and death attributable to GVHD in more than 30% of cases. In our smaller series, the frequency of hepatitic GVHD at 55% was similar. However, hepatitic changes in our patients had apparently little impact on treatment and prognosis, as more than 80% of our cases responded to standard immunosuppression, an outcome that was comparable to liver GVHD post-HSCT. These results were also similar to those described by Strasser et al,9 who reported in their original study on hepatitic GVHD that patients showed good responses to immunosuppression. Our results were therefore at variance with those of Akpek et al,10 but further studies in larger numbers of patients are required to validate our observations. Whether a difference in patient populations might be relevant has to be determined. Our study comprised mainly CML patients, as we treated relapses of other hematologic malignancies with a second full or nonmyeloablative transplant. Furthermore, scheduling and dosage of DLI might also affect the outcome of hepatitic GVHD.6 The exact dosage and schedule of DLI in
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the studies of Akpek et al10 have not been stated. Previous studies have shown that an escalating dose regimen might be associated with less GVHD than the bulk dose regimen. How this might have altered the outcome of liver GVHD remains unclear. In our study, the dose of DLI was gauged by response, an approach similar to an escalating dose regimen. This might have led to a more favorable outcome. Finally, because only a few cases of hepatitic GVHD post-HSCT and post-DLI have been reported, the prognostic impact of predominantly hepatitic LFT derangement requires further clarifiication. This is of clinical importance, because the grading of liver GVHD is currently only dependent on bilirubin level. Whether aminotransferase levels will also need to be taken into consideration in clinical grading of liver GVHD warrants further investigations.
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Acknowledgements This study is supported in part by the Kadoorie Charitable Foundation.
14 15
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