Abstract
Aim We present a case of fatal GVHD, a rare complication of solid organ transplantation, in a highly sensitized patient who was transplanted with a zero mismatch kidney-pancreas allograft. Methods HLA typing was performed by SSO, crossmatching by flow cytometry and antibody assessments by Luminex-based single antigen beads. Chimerism studies were performed by short tandem repeats (STR) on peripheral blood lymphocytes. Results A highly sensitized, 59 year old female (cPRA = 97%; HLA-A*01:01, 02:01; B*08:01,XX, C07:01,XX; DR*03:01,XX; DQB1*02:01,XX) with type 1 Diabetes Mellitus was transplanted with a zero mismatch deceased donor (HLA-A*01:01,XX; B*08:01,XX, C07:01,XX; DR*03:01,XX; DQB1*02:01,XX) kidney- pancreas. Four months post- transplant, the patient developed features of GVHD with fever, skin lesions, elevated liver enzymes and aplastic anemia. Development of GVHD was likely due to the absence of the HLA*A02:01 antigen on the donor tissue. Chimerism studies of the bone marrow showed 100% engraftment of the allograft donor. The patient was unresponsive to standard immunosuppressive treatment for GVHD. Two months after diagnosis, the patient received an unrelated umbilical cord blood transplant. Chimerism studies performed after cord blood transplant revealed successful donor engraftment of the white cell compartments. Nonetheless, the patient suddenly expired 22 days post-cord blood transplant as a consequence of GVHD. Conclusions A single mismatched HLA-antigen (in the donor vs host direction) resulted in significant donor cell proliferation and fatal GVHD even though the patient was on high dose immunosuppression and engrafted with a cord blood transplant. It appears that while standard immunosuppressive therapy blocked the recipient’s ability to mount an effective immunologic response against the kidney/pancreas, it failed to halt the GVHD process.
Published Version
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