Unsuccessful treatment of four patients with acute graft-vs-host disease after liver transplantation

Table 1 Clinic data of recipients with graft-vs-host disease

Case	Age (yr)/sex	Etiology	HCC criteria	MELD score	Onset day	Presenting symptoms	Changes in PLT count	Changes in WBC count
1	48/M	HCC/LC/HBV	UCSF	28	POD 23	Fever, rash, diarrhea, BMS, gastrointestinal bleeding	111 × 109/L to 12 × 109/L	8.69 × 109/L to 0.28 × 109/L
2	43/M	HCC/LC/HBV	Milan	21	POD 21	Fever, rash, diarrhea, BMS, gastrointestinal bleeding	124 × 109/L to 45 × 109/L	7.59 × 109/L to 0.11 × 109 /L
3	55/M	HCC/LC/HBV	Milan	23	POD 20	Fever, rash, diarrhea, BMS, gastrointestinal bleeding	273 × 109/L to 18 × 109/L	4.39 × 109/L to 0.03 × 109/L
4	56/F	LC/HBV	-	27	POD 21	Fever, rash, diarrhea, BMS, gastrointestinal bleeding	150 × 109/L to 1 × 109/L	5.12 × 109/L to 0.16 × 109/L

M: Male; F: Female; HCC: Hepatocellular carcinoma; LC: Liver cirrhosis; HBV: Hepatitis B virus; UCSF: University of California, San Francisco criteria for liver transplantation; BMS: Bone marrow suppression; POD: Post-operation day; MELD: Model for End-Stage Liver Disease; PLT: Platelet; WBC: White blood cell. Normal value for PLT is (100-300) × 10⁹/L; Normal value for WBC is (4-10) × 10⁹/L.

Table 2 Treatment for graft-vs-host disease and outcome

Case	Immunosuppression and supportive therapy	Time of death	Cause of death
1	Increased immunosuppressant (methylprednisolone 500 mg, iv, qd, for 3 d), then CsA and mycophenolate mofetil + G-CSF (0.075 mg, bid, for 11 d) + antibiotics (imipenem/cilastatin sodium, azithromycin, moxifloxacin, meropenem and teicoplanin) + anti-fungal (fluconazole)	POD 34	MOF and sepsis
2	Increased immunosuppressant (methylprednisolone 500 mg, iv, qd, for 2 d), then withdrawal (POD 29) of immunosuppressant + G-CSF (0.075 mg, bid, for 9 d) + IVIG (20 g, qd, for 9 d) + broad spectrum antibiotics (cefuroxime, ceftriaxone and imipenem/cilastatin) + anti-fungal (fluconazole)	POD 38	Gastrointestinal bleeding
3	Increased immunosuppressant (methylprednisolone 500 mg, qd, for 2 d), then withdrawal (POD 29) of immunosuppressant + thymosin α1 (Zadaxin 1.6 mg, qd, for 7 d) + G-CSF (0.075 mg, bid, for 7 d) + broad spectrum antibiotics (cefminox)	POD 35	Gastrointestinal bleeding and sepsis
4	Increased immunosuppressant (methylprednisolone 500 mg, iv, qd, for 2 d), then withdrawal (POD 30) of immunosuppressant + IVIG (20 g, qd, for 7 d) + thymosin α1 (Zadaxin 1.6 mg, qd, for 7 d) + G-CSF (0.075 mg, bid, for 5 d) + broad spectrum antibiotics (cefminox, cefoperazone/sulbactam)	POD 36	Gastrointestinal bleeding and sepsis

CsA: Cyclosporine A; G-CSF: Granulocyte colony-stimulating factor; IVIG: Intravenous immunoglobulin therapy; MOF: Multiple organ failure; POD: Post-operation day.