Graft-versus-host disease natural history, complications and prognosis

Jump to: navigation, search

Graft-versus-host disease

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Graft-versus-host disease from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Echocardiograph and Ultrasound

CT

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Graft-versus-host disease natural history, complications and prognosis On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Graft-versus-host disease natural history, complications and prognosis

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Graft-versus-host disease natural history, complications and prognosis

CDC on Graft-versus-host disease natural history, complications and prognosis

Graft-versus-host disease natural history, complications and prognosis in the news

Blogs on Graft-versus-host disease natural history, complications and prognosis

Directions to Hospitals Treating Type page name here

Risk calculators and risk factors for Graft-versus-host disease natural history, complications and prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Shyam Patel [2]

Overview

GvHD carries a high morbidity if not appropriately treated, and its natural history can result in organ failure and eventually death. Complications of GvHD include infection, organ damage and, in rare cases, squamous cell carcinoma or other immunosuppression-associated hematolymphoid malignancies. Poor prognostic factors include thrombocytopenia, severe jaundice, older age, >1 liter of diarrhea per day, hypoalbuminemia, and gastrointestinal ulceration. Multiple prognostic tools have been developed, including Johns Hopkins Hospital classification, Center for International Blood and Marrow Transplant Research classification, and the NIH consensus classification.

Natural History

The natural history of GvHD begins with a stem cell transplant and immunological interactions between donor cells and recipient tissue. Within a short period of time, even within a few days, a clinically significant immunologic response occurs. The natural course of the disease progresses to organ dysfunction in the skin, liver, and GI tract. This dysfunction can last for many weeks and even longer if left untreated. If treated appropriately with immunosuppression, the natural history of GvHD can be hampered, with inhibition of ongoing organ damage. If left untreated, worsening skin, liver, GI, and pulmonary manifestations will inevitably occur as the donor immune cells destroy host tissue. This can lead to:

  • Skin breakdown with subsequent infections and sepsis
  • Worsening GI dysfunction including high-volume diarrhea and dehydration, as well as sepsis from breakdown of intestinal mucosa

The natural history of GvHD can last for years, with a relapsing and remitting course. Different patients have different manifestations of the disease, and the natural history is thus variable. If patients develop steroid-refractory GvHD, the natural history tends to take an unfavorable course, with high morbidity and mortality. In this case, alternative immunosuppressive medications can be tried. However, the success rate for treatment of steroid-refractory GvHD is low, and the natural history of the disease results in death within a relatively short time.

Complications

  • Infections: A major complication of GvHD is the resulting immunosuppression that occurs after treatment. Treatment of GvHD focuses on abrogating the abnormal immune activation, and high dose steroids are typically administered. Late fungal infections and Pneumocystis carinii are common in patients who develop GvHD and receive treatment with immunosuppressive agents.[1]

Prognosis

A few different prognostic classifications have been developed for GvHD.[1]

  • Johns Hopkins Hospital
  • Center for International Blood and Marrow Transplant Research
  • NIH consensus classification: This classification proposes a global chronic severity score and includes the degree to which different organs are involved.

Prognostic factors include:

The risk of mortality is based upon certain clinical features[2]:

Low risk[2]:

High risk[2]:

  • Young age
  • Upper GI symptoms
  • Jaundice of mild severity
  • 1 liter per day of diarrhea
  • Extensive skin rash
  • Decline in albumin by more than 0.5 g/dl

Very high risk[2]:

References

  1. 1.0 1.1 1.2 1.3 1.4 Socié G, Ritz J (2014). "Current issues in chronic graft-versus-host disease". Blood. 124 (3): 374–84. doi:10.1182/blood-2014-01-514752. PMC 4102710. PMID 24914139.
  2. 2.0 2.1 2.2 2.3 Jacobsohn DA, Vogelsang GB (2007). "Acute graft versus host disease". Orphanet J Rare Dis. 2: 35. doi:10.1186/1750-1172-2-35. PMC 2018687. PMID 17784964.

Linked-in.jpg