Hepatobiliary disease after bone marrow transplant

ABSTRACT

Introduction

Bone marrow transplantation (BMT) is the standard treatment for several hematologic pathologies. Post-BMT patients may develop hepatobiliary complications that impact morbidity and mortality. The differential diagnosis may include drug-induced liver injury (DILI), sepsis-associated liver injury (SALI), sinusoidal obstruction syndrome (SOS), graft-versus-host disease (GVHD), viral hepatitis, ischemic and fulminant hepatitis, among others.

Area covered

Defining the etiology of hepatobiliary injury is challenging due to the overlapping symptoms. Thus, it is necessary to be aware of and understand the clinical characteristics of these hepatobiliary complications and provide adequate management with possible better outcomes. We reviewed the scientific literature focused on early hepatobiliary complications associated with BMT. We searched the PubMed database using the following descriptors: hepatic complications, drug-induced liver disease, graft-versus-host disease, cholestasis, sepsis, sinusoidal obstruction syndrome, cytomegalovirus, viral hepatitis, bone marrow transplantation, and hematopoietic stem cell transplantation.

Expert opinion

Post-BMT hepatobiliary complications comprise several differential diagnoses and are challenges for the hepatologist’s clinical practice. When evaluating these patients, it is necessary to consider the temporality between the use of certain medications, the increase in liver enzymes, and the presence of infection, in addition to applying diagnostic criteria and complementary tests for a specific diagnosis.

KEYWORDS:

• Bone marrow transplantation
• graft-versus-host disease
• hepatobiliary complications
• hepatotoxicity
• sinusoidal obstruction syndrome

Article highlights

• Post-BMT patients are at risk for several hepatobiliary complications (C-HEPBILI), such as drug-induced liver injury (DILI), GVHD, sepsis-associated liver injury (SALI), infectious complications, and sinusoidal obstruction syndrome (SOS), ischemic hepatitis and even fulminant hepatitis.

• During the early period after BMT, the most frequent complications are infectious, drug toxicity, SOS, and acute GVHD. The most common late complications are viral hepatitis flares, chronic GVHD, and hepatic iron overload.

• BMT patients who progress with elevated liver enzymes need to have the used medications and viral markers for hepatotropic and non-hepatotropic viruses evaluated.

• Jaundiced is associated with increased mortality not related to recurrence of the underlying disease; up to 50% after TB increases between 4 to 7 mg/dL.

• SOS carries a high mortality rate, and its early recognition is of fundamental importance

• Liver biopsy, when necessary, usually should be performed via the transjugular route to reduce the chances of bleeding complications.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or material discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or mending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.