P158 Could chimerism testing on orthotopic liver transplant patients lead to earlier graft versus host disease intervention and in turn more effective outcomes?

Abstract

Graft-versus-host disease (GVHD) is a rare but often fatal complication of orthotopic liver transplantation (OLT). Rash, fever, diarrhea and pancytopenia, all hallmarks of GVHD, are symptomatically similar to adverse drug reactions (ADR) or viral infections. In the absence of these classic symptoms, GVHD diagnosis is delayed. We present the case of a 62 year old male with alcoholic cirrhosis and hepatocellular carcinoma who received an allograft from a 0/10 HLA matched 19 year old male donor. Both were CMV seronegative and the retrospective T- and B-cell flow cytometric crossmatch were negative. Following an unremarkable early post-transplant course, the patient was discharged on post-operation day (POD) 8 only to return for a routine follow-up on POD17 complaining of diarrhea and subsequently symptoms of fever and leukopenia. Blood, bacterial stool cultures, and stool parasite antigen screen were all negative. Appropriate care was taken to treat ADR and rule out infection including EBV, CMV and C. difficile PCR. Despite temporary relief with medication adjustments the patient was readmitted on POD27 with recurring diarrhea, syncope, fever, worsening leukopenia and new-onset rash. Repeat blood and stool testing remained negative. While the skin biopsy did not meet criteria to make the diagnosis of GVHD, whole blood chimerism testing detected 90% donor cells consistent with GVHD. CD3+ T-lymphocyte chimerism testing yielded 100% donor cells. Bone marrow biopsy demonstrated hypocellular marrow ( > 20 years and degree of HLA mismatch) in the early OLT period are needed to determine if this can lead to better patient outcomes.