A major cause of morbidity and mortality following allogeneic hematopoietic cell transplantation (HCT) which continues to limit the broader application of this therapy.
Occurs when donor T cells respond to host antigens.
Current consensus is that clinical manifestations guide whether the signs and symptoms of graft versus host disease (GVHD) are acute, chronic, or an overlap syndrome.
Acute GVHD classically targets the skin, liver, and gastrointestinal tract. In contrast, chronic GVHD can involve almost any organ.
GVHD prophylaxis usually comprises a calcineurin-based inhibitor such as cyclosporine or tacrolimus (that blocks T-cell activation), administered with other immunosuppressants such as low-dose methotrexate or mycophenolate.
Optimum treatment of both acute and chronic forms of GVHD is yet to be fully defined, but current practice usually involves the use of systemic corticosteroids with additional immunosuppressants as required, often as part of a clinical trial.
Supportive care and monitoring are vital components of chronic GVHD management with emphasis on infection prophylaxis, physical therapy, nutritional status, pain control, and monitoring of drug-drug interactions and drug-related adverse effects.
Graft versus host disease (GVHD) is a major complication following allogeneic hematopoietic cell transplantation (HCT) and occurs when donor T cells respond to histoincompatible antigens on the host tissues.
Acute GVHD classically develops within the first 100 days of transplant or can occur beyond 100 days post transplant with persistent, recurrent, or late-onset symptoms. The principle target organs include the skin, liver, and gastrointestinal tract.
Chronic GVHD may emerge from acute disease (progressive type), develop following a period of resolution from acute disease (quiescent or interrupted type), or occur de novo. The manifestations can be variable, and are often similar to those seen in autoimmune diseases.
Overlap syndrome is characterized by clinical features that resemble a combination of both acute and chronic GVHD.
History and exam
- day +14 after HCT
- cyclophosphamide + total body irradiation (Cy/TBI) conditioning regimen
- peripheral blood stem cells as donor source
- new-onset painful mouth sores
- hyperpigmented skin lesions
- dry, gritty, and painful eyes
- dry, irritated vagina and vulva
- HLA disparity
- recipient or donor in older age group
- female donor with male recipient
- multiparous female donor
- advanced malignant condition
- high-intensity conditioning radiation regimen
- peripheral blood stem cells as source of transplant
- absent or suboptimal GVHD prophylaxis
- non-Asian or non-Hispanic ethnicity
- cytomegalovirus (CMV) seropositive
- low performance status score
- low socioeconomic status
- CT abdomen
- Doppler ultrasound of the liver
- tissue biopsy (skin, liver, GI tract, oral lesions, or lung)
- pulmonary function tests
- high-resolution CT chest
- bronchoalveolar lavage (BAL) and culture
- barium swallow or upper GI endoscopy
- 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) scan
Sung Choi, MD, MS
Department of Pediatrics and Communicable Diseases
Division of Pediatric Hematology Oncology/Blood and Marrow Transplantation
University of Michigan
SC is an author of a number of references cited in this topic.
Lyndsey Runaas, MD
Assistant Professor, Hematology and Oncology
Division of Hematology/Oncology
Medical College of Wisconsin
LR declares that she has no competing interests.
Dr Sung Choi and Dr Lyndsey Runaas would like to gratefully acknowledge Dr Pavan Reddy, a previous contributor to this topic. PR is an author of a number of references cited in this topic.
Corey Cutler, MD, MPH, FRCPC
Associate Professor of Medicine
Harvard Medical School
Dana-Farber Cancer Institute
CC declares that he has no competing interests.
Waseem Qasim, BMedSci (Hons), MBBS, MRCP (UK), MRCPCH, PhD
Institute of Child Health
Consultant in Paediatric Immunology & Bone Marrow Transplantation
Great Ormond Street Hospital
WQ declares that he has no competing interests.
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