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Overall aGVHD cascade Initiation and maintenance of aGVHD has been conceptualized into 4 phases with feedback loops that self-sustain the process. Although the effect of conditioning phase in aGVHD is not absolutely necessary, in many of the models it activates APCs, via tissue destruction, and improve APC capacity. It also, through release of gut bacteria, PAMPS and chemokines, can activate cellular components of innate immune system that can participate in direct tissue damage and contribute in cytokine storm. Host hematopoietic APCs have perhaps the most important role in initiation of GVHD, but this may depend on the model and the potential role of recipient APCs as well host non-hematopoietic APCs should not be ignored. Following antigen presentation, a strong cytokine response is initiated, promoting greater antigen presentation and recruitment of Teffs, and innate immune cells further contributing to the inflammatory cytokine milieu. Finally, the Teff cells, NK cells, macrophages and pro-inflammatory cytokines (e.g. TNF-α), will result in end organ damage, clinically recognized as aGVHD in the skin, lung, gut and liver. The resulting tissue damage, if not treated, will further escalate the disease, spiraling up the process to higher and more severe stages of GVHD pathology, which is extremely difficult to control.
Although initial definitions of acute GVHD required an onset of symptoms before 100 days post transplantation, the current National Institutes of Health (NIH) consensus criteria use clinical findings, rather than a set time period, to differentiate between acute and chronic GVHD.
Scale Index allows patients to be classified as to their functional impairment
40Disabled; requires special care and assistance. 30Severely disabled; hospital admission is indicated although death not imminent. 20Very sick; hospital admission necessary; active supportive treatment necessary. 10Moribund; fatal processes progressing rapidly. 0Dead
Liver biopsy is poses a significant risk of major bleeding since most patients are thrombocytopenic at the time of presentation with GVHD. Transjugular liver biopsy is a safer alternative if it can be adequately performed.
In Grade 1: No systemic Steroids is used. the most common prophylaxis regimen is the combination of cyclosporine and methotrexate. The cyclosporine is administered to reach a therapeutic target concentration, which varies according to the time from transplantation. A target concentration of 200 to 300 mcg/L is used during the first three to four weeks post transplant; then, if there is no GVHD, the target concentration is decreased to 100 to 200 mcg/L until three months after transplantation, and then tapered further. Patients who develop GVHD of any grade should have their cyclosporine dose adjusted to ensure a therapeutic level
The mechanism of prednisolone their effects may because of lympholytic effects and anti-inflammatory properties Gradual tapering is important to prevent a flare of GVHD. These efficacy and toxicity data suggested the use of mycophenolate plus glucocorticoids as the most promising combination
Day 28 post initiation of treatment complete response rates for methylprednisolone plus either etanercept, or mycophenolate, or denileukin, or pentostatin were 26, 60, 53, and 38 %, respectively. 9 month overall survival rates for these four treatment regimens were 47, 64, 49, and 47 percent, respectively. Cumulative incidences of severe infection were 48, 44, 62, and 57 percent, respectively.
Etanercept plus methylprednisolone as initial therapy for acute graft-versus-host disease, 2008 by Department of peds in Michigan medical school Showed that : Patients treated with etanercept plus steroids were significantly more likely to attain complete remission (CR) after 28 days than those treated with steroids alone (69 versus 33 percent)
Management of acute graft versus host disease
ACUTE GRAFT VERSUS HOST
Mahmoud A. Hashim Ahmed Khalaf
UAB School of Medicine
Bone Marrow Transplantation Unit
Multisystem Disorders due to immune
reaction caused by transplanted cells from a
non-identical donor (the graft) that
recognize recipient cells
(the host) as foreign, thus disease is caused
in the recipient organs.
It can be fatal in up to 15% of HSCT
Patients with GVHD are sub classified based upon the timing of presentation and the features
Classic acute GVHD
Cases present within 100 days of hematopoietic cell transplant (HCT).
Shows features of acute GVHD.
Diagnostic features of chronic GVHD are absent.
Persistent, recurrent, late onset acute GVHD
Cases present greater than 100 days post-HCT.
Shows features of acute GVHD.
Diagnostic features of chronic GVHD are absent.
Classic chronic GVHD
Cases may present at any time post-HCT.
Diagnostic features of chronic GVHD are present.
There are no features of acute GVHD.
Overlap syndrome “Acute on Chronic GVHD”
Cases may present at any time post-HCT .
Shows features of both chronic GVHD and acute GVHD.
CLINICAL MANIFESTATIONS AND GRADING
I. Maculopapular rash. “ 1st and most common symptom”
II. GI Symptoms “ 2nd commonest symptoms”
Diarrhea with or without Abd. Pain.
Persistent nausea and/or emesis.
Overall Grading of
If Karnofsky Performance <30%, then Grade 4
I. Clinical Evaluation
The diagnosis of aGvHD is
predominantly based on clinical
II. Histological Tests
A. Skin Biopsy is important in absence
of the classic symptoms.
Skin biopsy was not found to be
useful in predicting severity of
B. Rectosigmoid Biopsy was found to
be the most informative.
C. Transjugular liver biopsy can show
infiltration of the portal area,
pericholangitis and Bile duct
upper GI endoscopy as well as lower
endoscopic biopsy may show
Luminal Dilatation and Thckening of
small bowel wall.
There are many candidate biomarkers
but none are ready for clinical
The choice of initial therapy for patients with acute graft-verus-host
disease (GVHD) depends upon :
Overall grading of Acute GVHD.
Grade 1 GVHD Management
A. Topical steroids are the most commonly used skin-directed
therapy for acute GVHD.
B. Antihistamines may be used as supportive therapy for
patients with pruritus.
C. In Resistant grade 1 aGVHD,
Topical Tacrolimus may be useful.
D. Optimizing prophylactic agents
When acute GVHD of any grade develops, to ensure a
For those no longer receiving prophylaxis, the prior
prophylactic agent should be restarted again.
GRADE 2-4 GVHD
Patients with grade 2-4 disease are likely
to require addition of Systemic agents to
achieve a response and Optimizing
prophylactic calcineurin inhibitors
A. First Line of Treatment:
Most centres used 2 mg/kg /day of
methylprednisolone to be the standard
Oral beclomethasone, a non-
absorbable glucocorticoid, is added
for most patients with GI involvement.
Topical steroids can be added for
further control of Skin lesions.
Steroids are continued for several weeks in
responders and then gradually tapered over
a period of several months.
Patients who shows progression of disease
by day 5 or non-response by day 7 are
considered to have corticosteroid resistance.
Use of Steroids results in complete response
rates ranging from 25 to 40 %.
HOW TO TAPER THE STEROIDS AFTER INITIAL RESPONSE?
I. Tapering of steroid doses should begin as soon as GVHD
manifestations show major improvement.
II. Inappropriately rapid taper rates carry a risk of GVHD
exacerbation or recurrence, while inappropriately slow taper rates
increase the risk of steroid-related complications.
III. Doses should be gradual reduced 0.2 mg/kg/day every 3–5 days,
after prednisone doses are decreased to less than 20–30 mg/day,
slower tapering rate is required.
B. Second Line of Treatment:
Given in Patients who fail to respond
2 mg/kg/day Methylprednisolone for
5 d or progressive symptoms after 72
There is nostrong comparative data
showing superior efficacy for any
particular agent over others, so the
choice of a second-line regimen
should be guided by
1. Considerations of potential toxicity,
interactions with other agents
3. The familiarity of the physician with
4. The prior experience of the
1. Mycophenolate mofetil (MMF)
2. Etanercept “ Anti TNF Antibodies”
6. Extracorporeal Photopheresis
I. MYCOPHENOLATE MOFETIL (MMF)
Mechanism of Action:
I. MMF is a prodrug of mycophenolic acid (MPA), an inhibitor of inosine monophosphate
This is the rate-limiting enzyme in de novo synthesis of guanosine nucleotides.
T- and B-lymphocytes are more dependent on this pathway than other cell types are.
II. MPA can induce apoptosis of activated T-lymphocytes.
III. MMF dose in Adults is 2 gm/kg/day.
Dose related Cytopenia and gastrointestinal toxicity.
Moderate High possibility of Viral reactivation.
A recombinant human TNF-alpha
receptor fusion protein.
Given SC at a dose of 0.4 mg/kg
per dose, Twice/ week.
(maximum dose, 25 mg/week).
A purine analog, a potent inhibitor
of adenosine deaminase.
T and NK Cells Death occurs due to
accumulation of 2-deoxyadenosine
Dose: 1.5 mg/m2 IV /day for three
Pentostatin should be used with
caution in patients with
A 50 % dose reduction has been
suggested for patients with an
estimated creatinine clearance of
30 to 50 mL/min/1.73 m2
Exerts its immunosuppressive effect through
inhibition of mTOR.
Loading dose of 6 mg/m2 followed by a daily
dose of 3 mg/m2 daily for 13 days .
At a dose of 4 -5 mg/m2 without a loading
dose for 14 days.
Reversible cytopenia, hypertriglyceridemia,
and nephrotoxicity (HUS) and neurotoxicity
when combined with calcineurin inhibitors.
The use of Sirolimus has also been associated
with sinusoidal obstruction syndrome (SOS)
following conditioning regimens especially,
Humanized monoclonal antibodies
directed against the interleukin-2
receptor leading to prevention of T-
Recombinant fusion molecule of
human IL-2 and diphtheria toxin
that binds to the IL-2R-α and
triggers apoptosis in activated T
Infusion of ultraviolet-A irradiated
autologous peripheral lymphocytes
which have been collected by
apheresis and incubated with 8-
ECP induces apoptosis of all
leucocytes (including activatedn T-
cells) within 24 h of return.
Several studies have suggested that
ECP may have a role in the treatment
of acute GVHD.
Better results are expected in patients
with disease limited to the skin.
Side effects is mild including
hypotension, fevers and reduced
I. Advances in graft-versus-host disease biology and therapy,2013,
Bruce R. Blazar, William J. Murphy, and Mehrdad Abedi
II. Diagnosis and management of acute graft-versus-host disease,
2012, Fiona L. Dignan et al.
III. First and Second-Line Systemic Treatment of Acute Graft-versus-
host Disease: Recommendations of the American Society of Blood
and Marrow Transplantation, Paul J. Martin et al.
IV. Management of Acute GVHD, Uptodate.com
V. Extracorporeal photopheresis in the management of graft-versus-
host disease, Bredeson C et al.