MANAGEMENT OF ACUTE GRAFT VERSUS HOST DISEASE (GVHD)

Mahmoud A. Hashim

Ahmed KhalafVisiting Students

UAB School of Medicine

Hem-Onc Department Bone Marrow Transplantation Unit

DEFINITION 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 recipients.

PATHOGENESIS

CLASSIFICATION Patients with GVHD are sub classified based upon the timing of

presentation and the features present: 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.III. Jaundice

“Glucksberg Criteria”

Overall Grading of

Acute GVHD

If Karnofsky Performance <30%, then Grade 4

DIAGNOSESI. Clinical Evaluation The diagnosis of aGvHD is

predominantly based on clinical findings.

II. Histological TestsA. Skin Biopsy is important in

absence of the classic symptoms.

Skin biopsy was not found to be useful in predicting severity of disease.

B. Rectosigmoid Biopsy was found to be the most informative.

C. Transjugular liver biopsy can show Endothelialitis, Lymphocytic infiltration of the portal area, pericholangitis and Bile duct obstruction.

III. Imaging upper GI endoscopy

as well as lower endoscopic biopsy may show Luminal Dilatation and Thckening of small bowel wall.

IV. Biomarkers There are many

candidate biomarkers

but none are ready for clinical application.

MANAGEMENT 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 therapeutic level. 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 agents.

A. First Line of Treatment: Corticosteroids

Most centres used 2 mg/kg /day of methylprednisolone to be the standard primary dose.

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?

ConclusionI. 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 to 2 mg/kg/day Methylprednisolone for 5 d or progressive symptoms after 72 h.

There is no strong 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

2. Expense

3. The familiarity of the physician with the agent

4. The prior experience of the physician

Includes:

1. Mycophenolate mofetil (MMF) 

2. Etanercept “ Anti TNF Antibodies”

3. Pentostatin 

4. Sirolimus 

5. Basiliximab

6. Extracorporeal Photopheresis

I. MYCOPHENOLATE MOFETIL (MMF)

Mechanism of Action:I. MMF is a prodrug of mycophenolic acid (MPA), an inhibitor of

inosine monophosphate dehydrogenase (IMPDH). 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.

Side Effects Dose related Cytopenia and gastrointestinal toxicity. Moderate High possibility of Viral reactivation.

II. ETANERCEPT 

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).

Mechanism A purine analog, a potent

inhibitor of adenosine deaminase.

T and NK Cells Death occurs due to accumulation of 2-deoxyadenosine 5-triphosphate.

Dose: 1.5 mg/m2 IV /day for three days.

Pentostatin should be used with caution in patients with

renal insufficiency. A 50 % dose reduction has

been suggested for patients with an estimated creatinine clearance of 30 to 50 mL/min/1.73 m2

III. Pentostatin  

IV. SIROLIMUS (RAPAMYCIN)

Mechanism 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, Busulfan.

Mechanism Humanized monoclonal

antibodies directed against the interleukin-2 receptor leading to prevention of T-cell proliferation.

V. BASILIXIMAB

VI. DENILEUKIN DIFTITOX

MechanismRecombinant fusion molecule of human IL-2 and diphtheria toxin that binds to the IL-2R-α and triggers apoptosis in activated T cells.

VII.EXTRACORPOREAL PHOTOPHERESIS

Infusion of ultraviolet-A irradiated autologous peripheral lymphocytes which have been collected by apheresis and incubated with 8-methoxypsoralen.

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 hemoglobin level.

GvHD Diagnosing and Grading

Grade 1

Topical steroid

Grade 2-4

First Line

Systemic steroids

2mg/kg/day

Second Line

CONCLUSION

MMF

Etanercept

Pentostatin

Sirolimus

Extracorporeal

Photopheresis

BASILIXIMAB

REFERENCES I. Advances in graft-versus-host disease biology

and therapy,2013, Bruce R. Blazar, William J. Murphy, and Mehrdad Abedi http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3552454/

II. Diagnosis and management of acute graft-versus-host disease, 2012, Fiona L. Dignan et al.http://www.bcshguidelines.com/documents/bjh_9129_Rev_EV.pdf

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.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3404151/

IV. Management of Acute GVHD, Uptodate.comV. Extracorporeal photopheresis in the management

of graft-versus-host disease, Bredeson C et al.http://www.ncbi.nlm.nih.gov/pubmed/24764713