Graft versus Host Disease

Complication of allogeneic haematopoietic stem cell transplant (and occasionally blood transfusion) where the donor immunological cells recognise the host as foreign, causing a generalised immune response. Divided into:

Haematopoietic stem cell transplant is covered under Graft versus Host Disease.

Acute GvHD
- Classically 7-28 days following transplant
- Features:
  - Maculopapular rash
  - Diarrhoea
  - Intrahepatic cholestasis
- Staged based on extent of rash, volume of diarrhoea, and bilirubin
Chronic GvHD
Multiorgan dysfunction.
- Generally occurs >100 days post transplant
- Generalised organ involvement

Epidemiology and Risk Factors

Risk factors:

Allogeneic stem cell transplant
30-50% of cases.
CMV positive
Recipient frailty
HLA mismatch
↑ Donor age
↑ Recipient age
Inadequate immunosuppression
Peripheral blood utilised as stem cell source

Pathophysiology

Aetiology

Clinical Features

Clinical Features of Graft versus Host Disease
Properties	Acute	Chronic
Timing	Classically within 100 days	May occur at any time
Features	Skin Maculopapular rash Erythema GIT N/V/D Anorexia Mucositis Cholestasis	Absence of acute features Bronchiolitis obliterans Pleural effusions Pericardial effusion Conjunctivitis Alopecia Sclerotic skin Lichenoid oral and genital mucosa Oesophageal strictures

Definition relies more on the clinical features than the timing.

Late-onset acute GvHD describes the clinical features of acute GvHD, occurring after 100 days.

Assessment

History:

Exam:

Investigations

Bedside:

Laboratory:

Tissue biopsy
Affected regions; classically skin, liver, or rectal.

Imaging:

Other:

Diagnostic Approach and DDx

Management

Preventative immunosuppression in at-risk individuals
Pulsed immunosuppression

Resuscitation:

Specific therapy:

Pharmacological
- Pulsed methylprednisolone
- Additional immunosuppression
Procedural
Physical

Supportive care:

G
- Nutritional support
  PN may be required due to secretory diarrhoea.

Disposition:

Preventative:

Immunosuppression
- Corticosteroids
- Cyclosporin
- Mycophenolate mofetil

Marginal and Ineffective Therapies

Anaesthetic Considerations

Complications

Prognosis

Key Studies

References

Bersten, A. D., & Handy, J. M. (2018). Oh’s Intensive Care Manual. Elsevier Gezondheidszorg.