Pediatric Graft Versus Host Disease Follow-up

  • Author: Phillip Ruiz, Jr, MD, PhD; Chief Editor: Harumi Jyonouchi, MD   more...
 
Updated: Dec 13, 2011
 

Further Inpatient Care

  • Further inpatient care of graft versus host disease (GVHD) depends on initial response.
  • Maintenance immunosuppression with close monitoring is required.
  • Opportunistic infections may become severe and require intravenous (IV) antibiotics and supportive care.
Next

Further Outpatient Care

  • Regular follow-up with monitoring of immunosuppressive therapy is needed, as well as vigilance for developing chronic GVHD.
Previous
Next

Deterrence/Prevention

  • Effective prevention against GVHD includes the following:
    • Use of histocompatible donor and recipients
    • Use of immunosuppressive agents after bone marrow infusion (Most bone marrow transplant [BMT] teams currently use cyclosporine plus a brief course of methotrexate as the standard GVHD prophylaxis regime. Adding steroids has been proven beneficial in some trials. Other drugs alone or in combination include tacrolimus, antithymocyte globulin [ATG], and sirolimus.)
    • In vitro manipulation of the donor graft, such as marrow T-cell depletion
    • Possibly housing the patient in a pathogen-poor protected environment
  • The best prophylaxis against chronic GVHD is prevention of acute GVHD because de novo chronic GVHD is less common compared with incidence in patients with acute GVHD.
Previous
Next

Prognosis

  • Severe acute GVHD is the important cause of treatment failure after BMT. Survival rates vary from 90% in stage I, 60% in stage II or III, to almost 0% in stage IV. Death is often caused by infections, hemorrhage, and hepatic failure.
  • Severe chronic GVHD is associated with a higher mortality rate, mostly because of infection complications. Survivors are often severely disabled. The survival rate after onset of chronic GVHD is approximately 42%. Factors that predict death are progressive presentation (ie, acute GVHD followed by chronic GVHD), lichenoid skin changes on biopsy, and elevated serum bilirubin. A patient with one or more of these factors has a projected 6-year survival rate of 60%.
  • Mild chronic GVHD as with mild acute GVHD is associated with improved outcome in patients with leukemia because of graft-versus-leukemia (GVL) effect.
Previous
 
Contributor Information and Disclosures
Author

Phillip Ruiz, Jr, MD, PhD  Professor of Pathology, Department of Pathology and Surgery, Miller School of Medicine, University of Miami

Phillip Ruiz, Jr, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American Society for Clinical Pathology, American Society of Nephrology, American Society of Transplant Surgeons, American Society of Transplantation, Clinical Immunology Society, Florida Medical Association, New York Academy of Sciences, Pan American Medical Association, Southern Medical Association, and United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

Coauthor(s)

Yaxia Zhang, MD, PhD  Resident Physician, Department of Pathology, Jackson Memorial Hospital, University of Miami School of Medicine

Disclosure: Nothing to disclose.

Shoib Sarwar, MD, MPH  Fellowship in Cytopathology and Immunopathology, Department of Pathology, Jackson Memorial Hospital, University of Miami Miller School of Medicine

Shoib Sarwar, MD, MPH, is a member of the following medical societies: American College of Healthcare Executives, American Medical Association, American Society for Clinical Pathology, American Society of Cytopathology, College of American Pathologists, and United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

Specialty Editor Board

Ann O'Neill Shigeoka, MD †  Former Clinical Associate Professor, Department of Pediatrics, Division of Immunology-Rheumatology, University of Utah School of Medicine

Ann O'Neill Shigeoka, MD † is a member of the following medical societies: American Federation for Medical Research, Clinical Immunology Society, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

John Wilson Georgitis, MD  Consulting Staff, Lafayette Allergy Services

John Wilson Georgitis, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American Association for the Advancement of Science, American College of Chest Physicians, American Lung Association, American Medical Writers Association, and American Thoracic Society

Disclosure: Nothing to disclose.

David Pallares, MD  Clinical Assistant Professor, Department of Pediatrics, Division of Allergy and Immunology, University of Louisville School of Medicine

David Pallares, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology

Disclosure: Nothing to disclose.

Chief Editor

Harumi Jyonouchi, MD  Associate Professor, Division of Pulmonary, Allergy/Immunology, and Infectious Diseases, Department of Pediatrics, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Harumi Jyonouchi, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American Association of Immunologists, American Medical Association, Clinical Immunology Society, New York Academy of Sciences, Society for Experimental Biology and Medicine, Society for Mucosal Immunology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Mustafa Suterwala, MD, to the development and writing of this article.

References

  1. Barnes DW, Loutit JF, Micklem HS. "Secondary disease" of radiation chimeras: a syndrome due to lymphoid aplasia. Ann N Y Acad Sci. Oct 24 1962;99:374-85. [Medline].

  2. Simonsen M. Graft versus host reactions and their possible implications in man. Bibl Haematol. 1965;23:115-21. [Medline].

  3. Billingham RE. The biology of graft-versus-host reactions. Harvey Lect. 1966;62:21-78.

  4. Ferrara JL, Deeg HJ. Graft-versus-host disease. N Engl J Med. Mar 7 1991;324(10):667-74. [Medline].

  5. Filipovich AH, Weisdorf D, Pavletic S, et al. National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: I. Diagnosis and staging working group report. Biol Blood Marrow Transplant. Dec 2005;11(12):945-56. [Medline].

  6. Cho BS, Min CK, Eom KS, et al. Feasibility of NIH consensus criteria for chronic graft-versus-host disease. Leukemia. Oct 2 2008;[Medline].

  7. Ball LM, Egeler RM. Acute GvHD: pathogenesis and classification. Bone Marrow Transplant. Jun 2008;41 Suppl 2:S58-64. [Medline].

  8. Sun Y, Tawara I, Toubai T, et al. Pathophysiology of acute graft-versus-host disease: recent advances. Transl Res. Oct 2007;150(4):197-214. [Medline].

  9. Ferrara JL, Reddy P. Pathophysiology of graft-versus-host disease. Semin Hematol. Jan 2006;43(1):3-10. [Medline].

  10. Ferrara JL, Yanik G. Acute graft versus host disease: pathophysiology, risk factors, and prevention strategies. Clin Adv Hematol Oncol. May 2005;3(5):415-9, 428. [Medline].

  11. Kohler S, Pascher A, Junge G, et al. Graft versus host disease after liver transplantation - a single center experience and review of literature. Transpl Int. May 2008;21(5):441-51. [Medline].

  12. Parkman R. Chronic graft-versus-host disease. Curr Opin Hematol. Jan 1998;5(1):22-5. [Medline].

  13. Choi SW, Kitko CL, Braun T, et al. Change in plasma tumor necrosis factor receptor 1 levels in the first week after myeloablative allogeneic transplantation correlates with severity and incidence of GVHD and survival. Blood. Aug 15 2008;112(4):1539-42. [Medline].

  14. Paczesny S, Krijanovski OI, Braun TM, et al. A biomarker panel for acute graft versus host disease. Blood. Oct 2 2008;[Medline].

  15. Antin JH. Approaches to graft-vs-host disease. Pediatr Transplant. Dec 2005;9 Suppl 7:71-5. [Medline].

  16. Deeg HJ. How I treat refractory acute GVHD. Blood. May 15 2007;109(10):4119-26. [Medline].

  17. Ferrara JL. Novel strategies for the treatment and diagnosis of graft-versus-host-disease. Best Pract Res Clin Haematol. Mar 2007;20(1):91-7. [Medline].

  18. Koreth J, Matsuoka K, Kim HT, et al. Interleukin-2 and regulatory T cells in graft-versus-host disease. N Engl J Med. Dec 1 2011;365(22):2055-66. [Medline].

  19. Lopez F, Parker P, Nademanee A, et al. Efficacy of mycophenolate mofetil in the treatment of chronic graft-versus-host disease. Biol Blood Marrow Transplant. Apr 2005;11(4):307-13. [Medline].

  20. Diaz MA, Vicent MG, Gonzalez ME, et al. Risk assessment and outcome of chronic graft-versus-host disease after allogeneic peripheral blood progenitor cell transplantation in pediatric patients. Bone Marrow Transplant. Jul 26 2004;():[Medline].

  21. Faraci M, Dallorso S, Morreale G, et al. Surgery for acute graft-versus-host disease of the bowel: description of a pediatric case. J Pediatr Hematol Oncol. Jul 2004;26(7):441-3. [Medline].

  22. Flowers ME, Kansu E, Sullivan KM. Pathophysiology and treatment of graft-versus-host disease. Hematol Oncol Clin North Am. Oct 1999;13(5):1091-112, viii-ix. [Medline].

  23. Graubner UB, Liese J, Belohradsky BH. [Vaccination]. Klin Padiatr. Sep 2001;213 Suppl 1:A77-83. [Medline].

  24. Guinan EC, Bierer BE. Principles of Bone Marrow and Stem Cell Transplantation. Hematology of Infancy and Childhood. 1998;346-351.

  25. Horwitz ME, Sullivan KM. Chronic graft-versus-host disease. Blood Rev. Jan 2006;20(1):15-27. [Medline].

  26. Klingebiel T, Schlegel PG. GVHD: overview on pathophysiology, incidence, clinical and biological features. Bone Marrow Transplant. Apr 1998;21 Suppl 2:S45-9. [Medline].

  27. Kollman C, Howe CW, Anasetti C, et al. Donor characteristics as risk factors in recipients after transplantation of bone marrow from unrelated donors: the effect of donor age. Blood. Oct 1 2001;98(7):2043-51. [Medline].

  28. Lazarus HM, Vogelsang GB, Rowe JM. Prevention and treatment of acute graft-versus-host disease: the old and the new. A report from the Eastern Cooperative Oncology Group (ECOG). Bone Marrow Transplant. Mar 1997;19(6):577-600. [Medline].

  29. Messina C, Faraci M, de Fazio V, et al. Prevention and treatment of acute GvHD. Bone Marrow Transplant. Jun 2008;41 Suppl 2:S65-70. [Medline].

  30. Ringden O, Deeg HJ. Clinical Spectrum of Graft-Versus-Host Disease. 1997;525-550.

  31. Simpson D. New developments in the prophylaxis and treatment of graft versus host disease. Expert Opin Pharmacother. Jul 2001;2(7):1109-17. [Medline].

  32. Wysocki CA, Panoskaltsis-Mortari A, Blazar BR, Serody JS. Leukocyte migration and graft-versus-host disease. Blood. Jun 1 2005;105(11):4191-9. [Medline].

 
Previous
Next
 
Pathophysiological pathways and mechanisms of acute GVHD.
This boy developed stage III skin involvement with acute graft versus host disease (GVHD) in spite of receiving prophylaxis with cyclosporin A. The donor was an human leukocyte antigen (HLA)-matched sister; however, the sex disparity increased the risk for acute GVHD. Image courtesy of Mustafa S. Suterwala, MD.
This photo depicts the same boy who has progressed to grade IV graft versus host disease (GVHD). Both cyclosporin A and methylprednisolone had been administered in high dose intravenously. He later died with chronic pulmonary disease caused by chronic GVHD. Image courtesy of Mustafa S. Suterwala, MD.
Autologous graft versus host disease (GVHD) involving the skin of a patient's arm shortly after showing signs of engraftment after an autologous peripheral blood stem cell transplant for ovarian cancer. Image courtesy of Romeo A. Mandanas, MD, FACP.
Acute graft versus host disease (GVHD) involving desquamating skin lesions in a patient following allogeneic bone marrow transplantation for myelodysplasia. Image courtesy of Romeo A. Mandanas, MD, FACP.
Oral mucosal changes in a patient with chronic graft versus host disease (GVHD). Note the skin discoloration (vitiligo), which can result from GVHD. Image courtesy of Romeo A. Mandanas, MD, FACP.
Acute graft versus host disease (GVHD). Hematoxylin-stained and eosin-stained tissue shows dyskeratosis of individual keratinocytes and patchy vacuolization of the basement membrane. A moderate superficial dermal and perivascular lymphocytic infiltrate is also seen in this case. Image courtesy of Melanie K. Kuechler, MD.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.