Pediatric Graft Versus Host Disease Follow-up

Updated: Oct 07, 2015
  • Author: Phillip Ruiz, Jr, MD, PhD; Chief Editor: Harumi Jyonouchi, MD  more...
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Follow-up

Further Outpatient Care

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

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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.

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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 regimen. Adding steroids has been proven beneficial in some trials. Other drugs used 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.

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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.

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