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Tolerance to liver allograft after allogeneic hematopoietic cell transplantation for severe aplastic anemia from the same HLA-matched sibling donor

Bone Marrow Transplantation volume 47, pages 1128–1130 (2012)Cite this article

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Development of severe aplastic anemia (SAA) has been well described following non-A and non-B hepatitis or liver transplantation (LT), most often in the pediatric population. Its pathophysiology is unclear, but thought to be due to immune-mediated injury to liver and hematopoietic cells by unidentified viral organisms. In young and fit SAA patients, allogeneic hematopoietic cell transplantation (HCT) from HLA-matched sibling donor is the treatment of choice. Successful cases of HCT for SAA following LT have been described. However, all required long-term immunosuppressive therapy (IST) to prevent liver rejection or GVHD. Requirement for long-term immunosuppression predisposes transplant recipients to significant risks from opportunistic infections and secondary malignancies. While allograft tolerance has been reported in combined HCT and renal or lung transplantation from the same donor,1, 2, 3 outcomes of IST withdrawal following sequential LT and HCT for patients with SAA are unknown.

We report a case of a 30-year-old man who presented with fulminant hepatic failure with jaundice and encephalopathy (aspartate transaminase (AST) 2014 U/L (5–34 U/L), ALT 2725 U/L (7–40 U/L), bilirubin 521 μmol/L (<22 μmol/L), international normalized ratio (INR) 9.8 (0.80–1.20)). A detailed history and physical examination did not identify an etiology of his liver failure. Viral hepatitis markers, autoimmune and metabolic workup were all negative. A liver biopsy revealed severe hepatitis of nonspecific etiology, with parenchymal collapse and submassive necrosis, mild-to-moderate portal and parenchymal lymphoid infiltrate. The patient underwent a living-related LT from his sister within 2 weeks, and received post-LT immunosuppression with mycophenolate mofetil, tacrolimus and prednisone.

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Authors and Affiliations

  1. Department of Medicine, University of Toronto, Toronto, Ontario, Canada

    H Sun

  2. Multiorgan Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada

    G Therapondos

  3. Blood and Marrow Transplant Program, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada

    J Lipton & V Gupta

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  1. H Sun
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  2. G Therapondos
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  4. V Gupta
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Correspondence to V Gupta.

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HS collected all the material, wrote the case report; GT and JH contributed to the critical review of the report; VG (the senior responsible author) wrote the report and provided critical insights.

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Sun, H., Therapondos, G., Lipton, J. et al. Tolerance to liver allograft after allogeneic hematopoietic cell transplantation for severe aplastic anemia from the same HLA-matched sibling donor. Bone Marrow Transplant 47, 1128–1130 (2012). https://doi.org/10.1038/bmt.2011.222

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