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Graft versus host disease

Last reviewed: 25 Mar 2025
Last updated: 09 Apr 2025

Summary

Definition

History and exam

Key diagnostic factors

  • allogeneic hematopoietic cell transplantation (HCT) recipient
  • human leukocyte antigen (HLA) mismatch and unrelated donor
  • parous female donor
  • female donor with male recipient
  • new-onset painful mouth sores
  • hyperpigmented skin lesions
  • diffuse maculopapular rash
  • genital signs and symptoms
  • nausea, vomiting, abdominal pain, profuse diarrhea, and anorexia
Full details

Other diagnostic factors

  • joint stiffness or tightness
  • day +21 to day +25 after HCT
  • cyclophosphamide + total body irradiation (Cy/TBI) conditioning regimen
  • peripheral blood stem cell transplant
  • dry, gritty, and painful eyes
  • jaundice
  • hepatomegaly
  • scleroderma
Full details

Risk factors

  • HLA mismatch and unrelated donor
  • prior acute GVHD
  • recipient or donor in older age group
  • female donor with male recipient
  • parous female donor
  • type and stage of underlying malignant condition
  • high-intensity conditioning radiation regimen
  • peripheral blood stem cell transplant
  • donor lymphocyte infusion (DLI)
  • absent or suboptimal GVHD prophylaxis
  • white or black race
  • cytomegalovirus (CMV) seropositive
  • splenectomy
  • low performance status score
  • low socioeconomic status
Full details

Diagnostic tests

1st tests to order

  • CBC
  • serum electrolytes
  • liver functions tests
  • urinalysis
  • urine culture
  • blood culture
  • stool culture
  • viral polymerase chain reaction (PCR) studies
Full details

Tests to consider

  • CT abdomen
  • Doppler ultrasound of the liver
  • tissue biopsy (skin, gastrointestinal [GI] tract, liver, or lung)
  • pulmonary function tests
  • high-resolution CT chest
  • bronchoalveolar lavage (BAL) and culture
  • echocardiogram
  • barium swallow or upper gastrointestinal endoscopy
  • 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) scan
Full details

Emerging tests

  • serum biomarkers

Treatment algorithm

INITIAL

hematopoietic cell transplantation (HCT) recipient

ACUTE

acute: grade I

acute: grade II-IV

ONGOING

chronic

Contributors

Authors

Sung Won Choi, MD, MS
Sung Won Choi

Professor

Department of Pediatrics

Division of Pediatric Hematology Oncology/Blood and Marrow Transplantation

University of Michigan

Ann Arbor

MI

Disclosures

SWC is an author of a number of references cited in this topic.

Lyndsey Runaas, MD
Lyndsey Runaas

Assistant Professor, Hematology and Oncology

Division of Hematology/Oncology

Medical College of Wisconsin

Milwaukee

WI

Disclosures

LR declares that she has no competing interests.

Acknowledgements

Dr Sung Choi and Dr Lyndsey Runaas would like to gratefully acknowledge Dr Pavan Reddy, a previous contributor to this topic.

Disclosures

PR is an author of a number of references cited in this topic.

Peer reviewers

Corey Cutler, MD, MPH, FRCPC

Associate Professor of Medicine

Harvard Medical School

Dana-Farber Cancer Institute

Boston

MA

Disclosures

CC declares that he has no competing interests.

Waseem Qasim, BMedSci (Hons), MBBS, MRCP (UK), MRCPCH, PhD

Senior Lecturer

Institute of Child Health

Consultant in Paediatric Immunology & Bone Marrow Transplantation

Great Ormond Street Hospital

London

UK

Disclosures

WQ declares that he has no competing interests.

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