Acute graft-versus-host disease: Diagnosis, prophylaxis, and treatment

Abstract

Graft-versus-host disease (GvHD) results from the recognition of the hematopoietic stem cell transplantation (HSCT) recipient’s tissues as being foreign by immunocompetent donor T cells. GvHD remains a major cause of HSCT-related morbidity and mortality. Historically, acute GvHD is defined as GvHD that is evident prior to day 100 post-HSCT. However, acute GvHD can occur after this arbitrary HSCT milestone, and the diagnosis of acute GvHD is made based on the clinical presentation and other factors and not necessarily on the timing. The incidence of acute GvHD has been reported from 20% to 70%. Acute GvHD most commonly affects the skin ranging from mild erythema confined to the palms and soles to fullbody erythroderma with bullae. The GI tract and liver are common target organs of acute GvHD but are rarely affected without skin involvement. Because acute GvHD is associated with high morbidity and mortality rates, patients receive GvHD prophylaxis during the peri-HSCT period in an effort to prevent, or at least ameliorate, acute GvHD. The choice of medications for GvHD prophylaxis is based on the type of HSCT, the degree of histoincompatibility between the donor and the recipient, the hematopoietic stem cell (HSC) source, and the age of the donor and recipient at the time of HSCT. The diagnosis is most often made on a clinical basis and treated with immunosuppression. Mortality risk corresponds to the stage and grade of acute GvHD. The identification of biomarkers of acute GvHD is an active area of investigation. This chapter addresses the risk factors, clinical features, diagnostic studies, and management of acute GvHD as well as strategies for GvHD prophylaxis. Chapter 19 focuses on chronic GvHD.