Graft-versus-host disease after pediatric liver transplantation: A diagnostic challenge
Corresponding Author
Rabab Ali Al Attas
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Saudi Society of Bone Marrow Transplantation (SSBM), Riyadh, Saudi Arabia
Correspondence
Rabab Ali Al Attas, Immunology Laboratories, Department of Pathology and Lab Medicine, King Fahad Specialist Hospital-Dammam (KFSH-D), Al Mirikibat, Amer Bin Thabit St., Building 6, Office 2, Saudi Arabia, Dammam; Saudi Society of Bone Marrow Transplantation (SSBMT), Riyadh, Saudi Arabia.
Email: [email protected]
Search for more papers by this authorRazan M. Bader
Pediatric Liver Transplant, Liver Transplant Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
Search for more papers by this authorMiral Mashhour
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorZuhoor A. AlQahtani
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorAmani Mohammed
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorMasood Qahtani
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorZahid B. Arain
Liver Transplant, Liver Transplant Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
Search for more papers by this authorNadya Faraidy
Dermatology, Medicine Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
Search for more papers by this authorMohammad Awaji
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorGamil Mohammed
Dermatology, Medicine Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
Search for more papers by this authorHassan A. Alharbi
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorMariam AlZahrani
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorAmal Aqool
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorGhandorah Salim
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorCorresponding Author
Rabab Ali Al Attas
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Saudi Society of Bone Marrow Transplantation (SSBM), Riyadh, Saudi Arabia
Correspondence
Rabab Ali Al Attas, Immunology Laboratories, Department of Pathology and Lab Medicine, King Fahad Specialist Hospital-Dammam (KFSH-D), Al Mirikibat, Amer Bin Thabit St., Building 6, Office 2, Saudi Arabia, Dammam; Saudi Society of Bone Marrow Transplantation (SSBMT), Riyadh, Saudi Arabia.
Email: [email protected]
Search for more papers by this authorRazan M. Bader
Pediatric Liver Transplant, Liver Transplant Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
Search for more papers by this authorMiral Mashhour
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorZuhoor A. AlQahtani
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorAmani Mohammed
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorMasood Qahtani
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorZahid B. Arain
Liver Transplant, Liver Transplant Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
Search for more papers by this authorNadya Faraidy
Dermatology, Medicine Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
Search for more papers by this authorMohammad Awaji
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorGamil Mohammed
Dermatology, Medicine Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
Search for more papers by this authorHassan A. Alharbi
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorMariam AlZahrani
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorAmal Aqool
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorGhandorah Salim
Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
Search for more papers by this authorAbstract
Background
Graft-versus-host disease (GVHD) is a rare but serious complication after pediatric liver transplantation (LTx). Early diagnosis is difficult due to nonspecific presenting symptoms and non-pathognomonic skin histopathological features. The aim of this article was to describe a case of pediatric GVHD after LTx and to review available data on pediatric GVHD highlighting the diagnostic difficulty. We also propose a diagnostic algorithm to improve the diagnostic capability and increase clinical awareness about this potentially fatal condition.
Methods
We did a comprehensive literatures review on studies on GvHD following pediatric LTx between 1990 and February 2021, chimerism study by short tandem repeat (STR), HLA typing by sequence-specific oligonucleotide (SSO) method, and flowcytometry crossmatch.
Results
Our search yielded 23 case reports. The most common clinical manifestations were fever and rash (91%) followed by diarrhea. Mortality rate was 36.8% mainly due to sepsis and organ failure. Diagnosis was challenging and chimerism study to confirm donor engraftment was performed on only half of the cases. Prevalence of “donor dominant HLA one-way matching” typically occurs in homozygous parents-to-child transplantation was 75% in cases with HLA testing.
Conclusion
So far, there are no available standard diagnostic criteria for GVHD following pediatric LTx. Recognition of multiple risk factors through proper laboratory assessment can predict the occurrence, and early chimerism study can confirm suggestive clinical manifestation. The strong likelihood of developing GVHD in “donor one-way HLA match” and the severe problems imposed by this complication may justify avoidance of HLA homozygous parent's donation.
CONFLICT OF INTEREST
The authors confirm that there are no conflicts of interest.
Open Research
DATA AVAILABILITY STATEMENT
Data are available upon request from the corresponding author.
Supporting Information
| Filename | Description |
|---|---|
| petr14205-sup-0001-TableS1-5.docxWord 2007 document , 18.2 KB | Table S1-S5 |
| petr14205-sup-0002-Supinfo.xlsxExcel 2007 spreadsheet , 16.6 KB | Supplementary Material |
Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
REFERENCES
- 1Martin P. Increased disparity for minor histocompatibility antigens as a potential cause of increased GVHD risk in marrow transplantation from unrelated donors compared with related donors. Bone Marrow Transplant. 1991; 8(3): 217-223.
- 2Collins R, Cooper B, Nikaein A, et al. Graft-versus-host disease in a liver transplant recipient. Ann Intern Med. 1992; 116(5): 391-392.
- 3Inga MR, Deeg J, Lee SJ. Acute graft versus host disease after orthotopic liver transplantation. J Hematol Oncol. 2012; 5(50): 1-6.
- 4Roberts J, Ascher N, Lake J, et al. Graft vs. host disease after liver transplantation in humans: a report of four cases. Hepatology. 1991; 14(2): 274-281.
- 5Sanchez-Izquierdo J, Lumbreras C, Colina F, et al. Severe graft versus host disease following liver transplantation confirmed by PCR-HLA-B sequencing: report of a case and literature review. Hepatogastroenterology. 1996; 43(10): 1057-1061.
- 6Taylor A, Gibbs P, Sudhindran S, et al. Monitoring systemic donor lymphocyte macrochimerism to aid the diagnosis of graft-versus-host disease after liver transplantation. Transplantation. 2004; 77(3): 441-446.
- 7Arvind RM, Chandra S, Stewart Z, et al. Graft versus host disease after liver transplantation in adults: a case series, review of literature, and an approach to management. Transplantation. 2016; 100(12): 2661-2670.
- 8Rosen C, Ng C, Moore S, et al. Clinical and pathological features of graft-versus-host disease after liver transplantation: a case report and review of the literature. Clin Transplant. 1993; 7(1): 52-58.
- 9Wood A, Eghtesad B, Lindenmeyer C. Graft-versus-host disease after liver transplantation. Clin Liv Dis. 2020; 15: 81-84.
10.1002/cld.884 Google Scholar
- 10Bhaduri B, Tan K, Humphreys S, et al. Graft-versus-host disease after orthotopic liver transplantation in a child. Transplant Proc. 1990; 22(5): 2378-2380.
- 11Comenzo R, Malachowski M, Rohrer R, et al. Anomalous ABO phenotype in a child after an ABO-incompatible liver transplantation. N Engl J Med. 1992; 326(13): 867-870.
- 12DePaoli A, Bitran J. Graft-versus-host disease and liver transplantation. Ann Intern Med. 1992; 117(2): 170-171.
- 13Cattral M, Langnas A, Wisecarver J, et al. Survival of graft-versus-host disease in a liver transplant recipient. Transplantation. 1994; 57(8): 1271-1274.
- 14Whitington PF, Rubin C, Alonso E, et al. Complete lymphoid chimerism and chronic graft-versus-host disease in an infant recipient of a hepatic allograft from an HLA-homozygous parental living donor. Transplantation. 1996; 62(10): 1516-1519.
- 15Kiuchi T, Harada H, Matsukawa H, et al. One-way donor-recipient HLAmatching as a risk factor for graft-versus-host disease in living-related liver transplantation. Transpl Int. 1998; 11(Suppl 1): S383-S384.
- 16Hahn A, Baliga P. Rapid method for the analysis of peripheral chimerism in suspected graft-versus-host disease after liver transplantation. Liver Transpl. 2000; 6(2): 180-184.
- 17Dunn S, Krueger L, Butani L, et al. Late onset of severe graft-versus-host disease in a pediatric liver transplant recipient. Transplantation. 2001; 71: 1483-1485.
- 18Pinna A, Weppler D, Berho M, et al. Unusual presentation of graft-versus-host disease in pediatric liver transplant recipients: evidence of late and recurrent disease. Pediatr Transplant. 2002; 3(3): 236-242.
10.1034/j.1399-3046.1999.00043.x Google Scholar
- 19Schäppi MG, Belli DC, Rimensberger PC, et al. Fatal GvHD as a complication of liver transplantation for undetermined fulminant hepatic failure and associated aplastic anemia. Liver Transpl. 2006; 12(11): 1693-1697.
- 20Kamei H, Oike F, Fujimoto Y, et al. Fatal graft-versus-host disease after living donor liver transplantation: differential impact of donor-dominant one-way HLA matching. Liver Transpl. 2006; 12(1): 140-145.
- 21Yuksekkaya HA, Arikan C, Tumgor G, et al. Late-onset graft-versus-host disease after pediatric living-related liver transplantation for Langerhans cell histiocytosis. Pediatr Transplant. 2011; 15(6): E105-E109.
- 22Sharma A, Armstrong AE, Posner MP, et al. Graft-versus-host disease after solid organ transplantation: a single center experience and review of literature. Ann Transplant. 2012; 17(4): 133-139.
- 23Sheu J, Saavedra AP, Degar BA, et al. Bone marrow engraftment and associated dermatologic sequelae in a three-yr-old after liver transplantation. Pediatr Transplant. 2015; 19(2): E41-E46.
- 24Shimata K, Sakamoto R, Anan T, et al. Fatal graft-versus-host disease after living-donor liver transplantation from an HLA-DR-mismatched donor. Pediatr Transplant. 2017; 21(7):e13039.
- 25Pollack M, Speeg KV, Callander NS, et al. Severe, late-onset graft-versus-host disease in a liver transplant recipient documented by chimerism analysis. Hum Immunol. 2005; 66(1): 28-31.
- 26Kohler S, Pascher A, Junge G, et al. Graft versus host disease after liver transplantation–a single center experience and review of literature. Transpl Int. 2008; 21(5): 441-451.
- 27Jeanmonod P, Hubbuch M, Grünhage F, et al. Graft-versus-host disease or toxic epidermal necrolysis: diagnostic dilemma after liver transplantation. Transpl Infect Dis. 2012; 14(4): 422-426.
- 28Kakotrichi A, Hind J. Graft-versus-host disease in paediatric liver transplantation: a review of the literature. S Afr Med J. 2017; 107(10): 12133.
- 29Sudhindran S, Taylor A, Delriviere L, et al. Treatment of graft-versus-host disease after liver transplantation with basiliximab followed by bowel resection. Am J Transplant. 2003; 3(8): 1024-1029.
- 30Riñón M, Maruri N, Arrieta A, et al. Selective immunosuppression with daclizumab in liver transplantation with graft-versus-host disease. Transplant Proc. 2002; 34(1): 109-110.
- 31Deeg H, Loughran T, Storb R, et al. Treatment of human acute graft-versus-host disease with antithymocyte globulin and cyclosporine with or without methylprednisolone. Transplantation. 1985; 40(2): 162-166.
- 32Lehner F, Becker T, Sybrecht L, et al. Successful outcome of acute graft-versus-host disease in a liver allograft recipient by withdrawal of immunosuppression. Transplantation. 2002; 73(2): 307-310.
- 33Wang B, Lu Y, Yu L, et al. Diagnosis and treatment for graft-versus-host disease after liver transplantation: two case reports. Transplant Proc. 2007; 39(5): 1696-1698.
- 34Andres AM, Santamaría ML, Ramos E, et al. Graft-vs-host disease after small bowel transplantation in children. J Pediatr Surg. 2010; 45(2): 330-336.
- 35Taylor A, Gibbs P, Bradley JA. Acute graft versus host disease following liver transplantation: the enemy within. Am J Transplant. 2004; 4(4): 466-474.
- 36Lerner K, Kao G, Storb R, et al. Histopathology of graft-vs.-host reaction (GvHR) in human recipients of marrow from HL-A-matched sibling donors. Transplant Proc. 1974; 6(4): 367-371.
- 37Kuykendall TD, Smoller BR. Lack of specificity in skin biopsy specimens to assess for acute graft-versus-host disease in initial 3 weeks after bone-marrow transplantation. J Am Acad Dermatol. 2003; 49(6): 1081-1085.
- 38Socié G, Mary J-Y, Lemann M, et al. Prognostic value of apoptotic cells and infiltrating neutrophils in graft-versus-host disease of the gastrointestinal tract in humans: TNF and Fas expression. Blood. 2004; 103(1): 50-57.
- 39Smith D, Agura E, Netto G, et al. Liver transplant-associated graft-versus-host disease. Transplantation. 2003; 75(1): 118-126.
- 40Perri R, Assi M, Talwalkar J, et al. Graft vs. host disease after liver transplantation: a new approach is needed. Liver Transpl. 2007; 13(8): 1092-1099.
- 41Thaler M, Shamiss A, Orgad S, et al. The role of blood from HLA-homozygous donors in fatal transfusion-associated graft-versus-host disease after open-heart surgery. N Engl J Med. 1989; 321(1): 25-28.
- 42Billingham RE. The biology of graft-versus-host reactions. Harvey Lect. 1966–1967; 62: 21-78.
- 43Schöniger-Hekele M, Müller C, Kramer L, et al. Graft versus host disease after orthotopic liver transplantation documented by analysis of short tandem repeat polymorphisms. Digestion. 2006; 74(3–4): 169-173.
- 44Pageaux G, Perrigault P, Fabre J, et al. Lethal acute graft-versus-host disease in a liver transplant recipient: relations with cell migration and chimerism. Clin Transplant. 1995; 9(1): 65-69.
- 45Peng B, Liu H, Zhuang Q, et al. Detecting chimerism contributes to diagnosis of graft versus host disease after orthotopic liver transplantation. Hepatobiliary Pancreat Dis Int. 2018; 17(4): 363-366.
- 46Schrager JJ, Vnencak-Jones CL, Graber SE, et al. Use of short tandem repeats for DNA fingerprinting to rapidly diagnose graft-versus-host disease in solid organ transplant patients. Transplantation. 2006; 81(1): 21-25.
- 47Oi-Lin Ng I, Chan K-L, Shek W-H, et al. High frequency of chimerism in transplanted livers. Hepatology. 2003; 38(4): 989-998.
- 48Hove W, Hoek BV, Bajema IM, et al. Extensive chimerism in liver transplants: vascularendothelium, bile duct epithelium, and hepatocytes. Liver Transpl. 2003; 9: 552-556.
- 49Alexander SI, Smith N, Hu M, et al. Chimerism and tolerance in a recipient of a deceased-donor liver transplant. N Engl J Med. 2008; 358: 369-374.
- 50Domiati-Saad R, Klintmalm G, Netto G, et al. Acute graft versus host disease after liver transplantation: patterns of lymphocyte chimerism. Am J Transplant. 2005; 5: 2968-2973.
- 51Korkmaz K, Ten Hove W, de Rooij B-JF, et al. Acute cellular rejection is associated with matrix metalloproteinase-2 genotype chimerism after orthotopic liver transplantation. Transplant Proc. 2013; 45: 558-563.
- 52Starzl TE, Demetris AJ, Tru M, et al. Chimerism after liver transplantation for type IV glycogen storage disease and type 1 Gaucher’s disease. N Engl J Med. 1993; 328: 745-749.
- 53Wood K, Sachs D. Chimerism and transplantation tolerance: cause and effect. Immunol Today. 1996; 17(12): 584-587.
- 54Starzl T, Demetris A, Trucco M, et al. Cell migration and chimerism after whole-organ transplantation: the basis of graft acceptance. Hepatology. 1993; 17(6): 1127-1152.
- 55Triulzi D, Nalesnik M. Microchimerism, GVHD, and tolerance in solid organ transplantation. Transfusion. 2001; 41(3): 419-426.
- 56Jonsson J, Hogan P, Balderson G, et al. Human liver transplant perfusate: an abundant source of donor liver-associated leukocytes. Hepatology. 1997; 26(5): 1111-1114.
- 57Schlitt H, Kanehiro H, Raddatz G, et al. Persistence of donor lymphocytes in liver allograft recipients. Transplantation. 1993; 56(4): 1001-1007.
- 58Chaib E, Silva FD, Figueira ER, et al. Graft-versus-host disease after liver transplantation. Clinics. 2011; 66(6): 1115-1118.
- 59Schlitt H, Raddatz G, Steinhoff G, et al. Passenger lymphocytes in human liver allografts and their potential role after transplantation. Transplantation. 1993; 56(4): 951-955.
- 60Meves A, el-Azhary RA, Talwalkar JA, et al. Acute graft-versus-host disease after liver transplantation diagnosed by fluorescent in situ hybridization testing of skin biopsy specimens. J Am Acad Dermatol. 2006; 55(4): 642-646.
- 61Matsukuma K, Wei D, Sun K, et al. Diagnosis and differential diagnosis of hepatic graft versus host disease (GVHD). J Gastrointest Oncol. 2016; 7(Suppl 1): S21-31.
- 62Joysey V, Wood H, Ramsbottom S, et al. Lymphocyte chimaerism after organ transplantation. Transplant Proc. 1992; 24(6): 2519-2522.
- 63Arrieta A, Maruri N, Riñón M, et al. Confirmation of graft-versus-host disease by HLA typing after liver transplantation. Transplant Proc. 2002; 34(1): 278-279.
- 64Akbulut S. Intussusception due to inflammatory fibroid polyp: a case report and comprehensive literature review. World J Gastroenterol. 2012; 18(40): 5745-5752.
- 65Green T, Hind J. Graft-versus-host disease in paediatric solid organ transplantation: a review of the literature. Pediatr Transplant. 2016; 20(5): 607-618.
- 66Anderson K, Weinstein H. Transfusion-associated graft-versus-host disease. N Engl J Med. 1990; 323(5): 315-321.
- 67Norris S, Collins C, Doherty D, et al. Resident human hepatic lymphocytes are phenotypically different from circulating lymphocytes. J Hepatol. 1998; 28(1): 84-90.
- 68Collins R, Anastasi J, Terstappen L, et al. Brief report: donor-derived long-term multilineage hematopoiesis in a liver-transplant recipient. N Engl J Med. 1993; 328(11): 762-765.
- 69Fowler D, Gress R. Th2 and Tc2 cells in the regulation of GVHD, GVL, and graft rejection: considerations for the allogeneic transplantation therapy of leukemia and lymphoma. Leuk Lymphoma. 2000; 38(3–4): 221-234.
- 70Kang W, Hwang S, Song G, et al. Acute graft-vs-host disease after liver transplantation: experience at a high-volume liver transplantation center in Korea. Transplant Proc. 2016; 48(10): 3368-3372.
- 71Wang X, Lo CM, Chen L, et al. Hematopoietic Chimerism in liver transplantation patients and hematopoietic stem/progenitor cells in adult human liver. Hepatology. 2012; 56: 1557-1566.
- 72Grosskreutz C, Gudzowaty O, Shi P, et al. Partial HLA matching and RH incompatibility resulting in graft versus host reaction and Evans syndrome after liver transplantation. Am J Hematol. 2008; 83(7): 599-601.
- 73Hanaway M, Buell J, Musat A, et al. Graft-versus-host disease in solid organ transplantation. Graft. 2001; 4: 205-208.
10.1177/152216280100400306 Google Scholar
- 74Chan E, Larson AM, Gernsheimer TB, et al. Recipient and donor factors influence the incidence of graft-vs.-host disease in liver transplant patients. Liver Transpl. 2007; 13(4): 516-522.
- 75Elfeki M, Pungpapong S, Genco PV, et al. Graft-versus-host disease after orthotopic liver transplantation: multivariate analysis of risk factors. Clin Transplant. 2015; 29(12): 1063-1066.
- 76Bilodeau A, Prasil P, Cloutie R, et al. Hereditary multiple intestinal atresia: thirty years later. J Pediatr Surg. 2004; 39(5): 726-730.
- 77Cho E-H, Suh K-S, Yang SH, et al. Acute graft versus host disease following living donor liver transplantation: first Korean report. Hepatogastroenterology. 2007; 54(79): 2120-2122.
- 78Sale G, Shulman H, McDonald G, et al. Gastrointestinal graft-versus-host disease in man. A clinicopathologic study of the rectal biopsy. Am J Surg Pathol. 1979; 3(4): 291-299.
- 79Burdick J, Vogelsang G, Smith W, et al. Severe graft-versus-host disease in a liver-transplant recipient. N Engl J Med. 1988; 318(11): 689-691.
- 80Squires RH, Ng V, Romero R, et al. Evaluation of the pediatric patient for liver transplantation: 2014 practice guideline by the American Association for the Study of Liver Diseases, American Society of Transplantation and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Hepatology. 2014; 60: 362-397.
- 81Hadzic N, Heaton N, Francavilla R. Paediatric sclerosing cholangitis associated with primary immunodeficiencies. J Pediatr Gastroenterol Nutr. 1999; 28(5): 2-5.
- 82Tait B, Süsal C, Gebel HM, et al. Transplantation Consensus guidelines on the testing and clinical management issues associated with HLA and non-HLA antibodies in transplantation. Transplantation. 2013; 95(1): 19-47.
- 83Kruskall M, Alper C, Awdeh Z, et al. HLA-homozygous donors and transfusion-associated graft-versus-host disease. N Engl J Med. 1990; 322(14): 1005-1006.
- 84Schulman JM, Yoon C, Schw J, et al. Absence of peripheral blood chimerism in graft-vs-host disease following orthotopic liver transplantation: case report and review of the literature. Int J Dermatol. 2014; 53(11): e492-e498.
Citing Literature
