Canterbury DHB

Context

Acute Graft Versus Host Disease (aGvHD)

In This Section

Clinical Features and Grading of Severity

Pathogenesis of Acute GvHD

Diagnosis of acute GVHD

Initial Management of Acute GvHD

Supportive Care

Clinical Features and Grading of Severity

Acute GvHD is seen following allogeneic SCT, both standard and RIC, and is more common in mismatched or unrelated SCTs. A similar syndrome is seen very occasionally following autologous SCT. Engraftment and subsequent GvHD may be seen inadvertently following infusion of non irradiated cells into immunoincompetent patients, or when blood donors of the same HLA type are used, i.e., usually following the use of a family donor. The onset of aGvHD is usually between days +10 to +30 with a median of around day 20.

Risk Factors for GvHD

Acute GvHD

Chronic GvHD

Increased risk

HLA mismatch

Older recipients

Older donors

High dose TBI

Donor lymphocyte infusion

Peripheral blood > BM > CB

Increased risk

Older age

Prior acute GvHD

HLA mismatch

Transplant from alloimmune female donor

Reduced Risk

T cell depletion

Non Myeloablative Conditioning

Reduced Risk

Cord blood

 

Clinical Staging of Acute Graft Versus Host Disease

Stage

Skin
(% BSA of rash)

Liver
(bilirubin in mcmol/L)

Intestinal Tract
(daily stool volume)

0

None

None

None

1

<25%

34-50

>500 mL

2

25-50%

51-102

>1000 mL +/- blood or cramping

3

Generalized erythroderma

103-255

>1500 mL

4

Generalised erythroderma with bullae formation and desquamation

>255

Severe abdominal pain, with or without ileus

 

Clinical Grading of Severity of Acute Graft Versus Host Disease

Overall grade (IBMTR)

Criteria

1 year mortality (odds ratio compared to no GvHD)

A

Stage 1 skin only

0.8

B

Maximum stage 2 in any organ

0.8

C

Maximum stage 3 in any organ

1.4

D

Stage 4 in any organ

12.3

Overall grade (Glucksberg)

Criteria

1 year mortality (odds ratio compared to no GvHD)

I

Skin stage 1 or 2 only (no liver or gut aGvHD)

0.8

II

Up to stage 1 liver or gut, up to stage 3 skin

0.8

III

Up to stage 4 liver, up to stage 3 in any other organ

2.2

IV

Stage 4 skin or gut, ECOG/WHO performance status 4 or Karnofsky performance score < 30%

13.1

The IBMTR and Glucksberg criteria were prospectively validated in 607 patients receiving myeloablative T cell-replete allogeneic stem cell transplants between 1996 and 1999. Both systems were predictive of mortality at 100 days and one year post-transplant.

Further reading:

Pathogenesis of Acute GvHD

The pathogenesis of acute GvHD is multifactorial and includes:

Acute GvHD results in four specific consequences:

  1. Direct organ injury requiring immunosuppressive therapy
  2. Secondary risks of infection
  3. Increased risk of chronic GvHD
  4. An enhanced anti-tumour effect

Diagnosis of acute GVHD

This is established clinically and if necessary histologically. The differential diagnosis depends on the exact tissue(s) involved. The conditions below all need to be considered when making a diagnosis of GvHD:

Liver

GI tract

About this Canterbury DHB document (9068):

Document Owner:

Andrew Butler (see Who's Who)

Issue Date:

December 2016

Next Review:

December 2018

Keywords:

Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer

Topic Code: 9068