Graft-versus-host disease classification: Difference between revisions
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==Overview== | ==Overview== | ||
Classification can be related to time-of-onset or to disease severity. Time-of-onset classification divides GvHD into acute or chronic. Severity classification divides GvHD into stages and grades, as defined by the International Bone Marrow Transplant Registry (IBMTR). | Classification can be related to time-of-onset or to disease severity. Time-of-onset classification divides GvHD into acute or chronic, based on the key time point of 100 days. Severity classification divides GvHD into stages and grades, as defined by the International Bone Marrow Transplant Registry (IBMTR). The ultimate grade of GvHD is determined by the stages of the individual organs affected. Grade 1 GvHD, for example, is characterized by skin involvement but without liver or GI involvement. | ||
==Classification== | ==Classification== | ||
Clinically, graft-versus-host-disease is divided into [[Acute (medical)|acute]] and [[chronic (medicine)|chronic]] forms. | *Clinically, graft-versus-host-disease is divided into [[Acute (medical)|acute]] and [[chronic (medicine)|chronic]] forms. | ||
* The ''acute'' or ''fulminant'' form of the disease (aGVHD) is normally observed within the first 100 days post-transplant<ref>[http://www.marrow.org/PHYSICIAN/improved_management_gvhd.html Graft versus Host Disease], from the [[National Marrow Donor Program]]</ref>, and is a major challenge to transplants owing to associated morbidity and mortality<ref>{{cite journal |author=Goker H, Haznedaroglu IC, Chao NJ |title=Acute graft-vs-host disease: pathobiology and management |journal=Exp. Hematol. |volume=29 |issue=3 |pages=259–77 |year=2001 |pmid=11274753 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0301-472X(00)00677-9}}</ref>. | **The ''[[acute]]'' or ''[[fulminant]]'' form of the disease (aGVHD) is normally observed within the first 100 days post-transplant<ref>[http://www.marrow.org/PHYSICIAN/improved_management_gvhd.html Graft versus Host Disease], from the [[National Marrow Donor Program]]</ref>, and is a major challenge to transplants owing to associated morbidity and mortality<ref>{{cite journal |author=Goker H, Haznedaroglu IC, Chao NJ |title=Acute graft-vs-host disease: pathobiology and management |journal=Exp. Hematol. |volume=29 |issue=3 |pages=259–77 |year=2001 |pmid=11274753 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0301-472X(00)00677-9}}</ref>. | ||
* The ''chronic'' form of graft-versus-host-disease (cGVHD) normally occurs after 100 days. The appearance of moderate to severe cases of cGvHD adversely influences long-term survival <ref>{{cite journal |author=Lee SJ, Vogelsang G, Flowers ME |title=Chronic graft-versus-host disease |journal=Biol. Blood Marrow Transplant. |volume=9 |issue=4 |pages=215–33 |year=2003 |pmid=12720215 |doi=10.1053/bbmt.2003.50026 |url=}}</ref>. | **The ''[[Chronic (medical)|chronic]]'' form of graft-versus-host-disease (cGVHD) normally occurs after 100 days. The appearance of moderate to severe cases of cGvHD adversely influences long-term survival <ref>{{cite journal |author=Lee SJ, Vogelsang G, Flowers ME |title=Chronic graft-versus-host disease |journal=Biol. Blood Marrow Transplant. |volume=9 |issue=4 |pages=215–33 |year=2003 |pmid=12720215 |doi=10.1053/bbmt.2003.50026 |url=}}</ref>. | ||
* The overlap syndrome includes features of both acute and chronic GvHD. This is less commonly encountered.<ref name="pmid24914139">{{cite journal| author=Socié G, Ritz J| title=Current issues in chronic graft-versus-host disease. | journal=Blood | year= 2014 | volume= 124 | issue= 3 | pages= 374-84 | pmid=24914139 | doi=10.1182/blood-2014-01-514752 | pmc=4102710 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914139 }} </ref> | **The overlap syndrome includes features of both [[Acute (medicine)|acute]] and [[Chronic (medical)|chronic]] GvHD. This is less commonly encountered.<ref name="pmid24914139">{{cite journal| author=Socié G, Ritz J| title=Current issues in chronic graft-versus-host disease. | journal=Blood | year= 2014 | volume= 124 | issue= 3 | pages= 374-84 | pmid=24914139 | doi=10.1182/blood-2014-01-514752 | pmc=4102710 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24914139 }} </ref> | ||
This distinction is not arbitrary: acute and chronic GvHD appear to involve different [[immune cell]] subsets, different [[cytokine]] profiles, somewhat different host targets, and respond differently to treatment. | *This distinction is not arbitrary: acute and chronic GvHD appear to involve different [[immune cell]] subsets, different [[cytokine]] profiles, somewhat different host targets, and respond differently to treatment. | ||
The severity classification is based on skin, liver, and GI involvement. The [[International Bone Marrow Transplant Registry]] (IBMTR) has created a staging and grading system.<ref name="pmid23802653">{{cite journal| author=Qian L, Wu Z, Shen J| title=Advances in the treatment of acute graft-versus-host disease. | journal=J Cell Mol Med | year= 2013 | volume= 17 | issue= 8 | pages= 966-75 | pmid=23802653 | doi=10.1111/jcmm.12093 | pmc=3780546 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23802653 }} </ref> In this classification, GvHD is divided as follows: | *The severity classification is based on skin, liver, and GI involvement. The [[International Bone Marrow Transplant Registry]] (IBMTR) has created a staging and grading system.<ref name="pmid23802653">{{cite journal| author=Qian L, Wu Z, Shen J| title=Advances in the treatment of acute graft-versus-host disease. | journal=J Cell Mol Med | year= 2013 | volume= 17 | issue= 8 | pages= 966-75 | pmid=23802653 | doi=10.1111/jcmm.12093 | pmc=3780546 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23802653 }} </ref> In this classification, GvHD is divided as follows: | ||
Skin: | '''Skin''': | ||
* Stage 0: no rash | * Stage 0: no rash | ||
* Stage 1: [[maculopapular rash]] < 25% of body surface area | * Stage 1: [[maculopapular rash]] < 25% of body surface area | ||
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* Stage 4: generalized [[erythema]] plus [[bullous formation]] | * Stage 4: generalized [[erythema]] plus [[bullous formation]] | ||
Liver: | '''Liver''': | ||
* Stage 0: bilirubin < 2 mg/dl | * Stage 0: [[bilirubin]] < 2 mg/dl | ||
* Stage 1: bilirubin 2-3 mg/dl | * Stage 1: [[bilirubin]] 2-3 mg/dl | ||
* Stage 2: bilirubin 3.1-6 mg/dl | * Stage 2: [[bilirubin]] 3.1-6 mg/dl | ||
* Stage 3: bilirubin 6.1-15 mg/dl | * Stage 3: [[bilirubin]] 6.1-15 mg/dl | ||
* Stage 4: bilirubin >15 mg/dl | * Stage 4: [[bilirubin]] >15 mg/dl | ||
GI: | '''GI''': | ||
* Stage 0: < 50cc stool per day or persistent nausea | * Stage 0: < 50cc stool per day or persistent [[Nausea and vomiting|nausea]] | ||
* Stage 1: 500-999cc stool per day | * Stage 1: 500-999cc [[Stools|stool]] per day | ||
* Stage 2: 1000-1500cc stool per day | * Stage 2: 1000-1500cc [[Stools|stool]] per day | ||
* Stage 3: > 1500cc stool per day | * Stage 3: > 1500cc [[Stools|stool]] per day | ||
* Stage 4: severe abdominal pain or ileus | * Stage 4: severe [[abdominal pain]] or [[ileus]] | ||
The conglomeration of staging gives rise to a grade. The grading system is as follows: | The conglomeration of staging gives rise to a grade. The grading system is as follows: | ||
* Grade 1: skin stage 1-2 with no liver or GI involvement | * Grade 1: skin stage 1-2 with no [[liver]] or GI involvement | ||
* Grade 2: skin stage 3 or liver stage 1 or GI stage 1 | * Grade 2: skin stage 3 or [[liver]] stage 1 or GI stage 1 | ||
* Grade 3: skin with any stage or liver stage 2-3 or GI stage 2-4 | * Grade 3: skin with any stage or [[liver]] stage 2-3 or GI stage 2-4 | ||
* Grade 4: skin stage 4 or liver stage 4 or GI with any stage | * Grade 4: skin stage 4 or [[liver]] stage 4 or GI with any stage | ||
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{{main|Transfusion-associated graft versus host disease}} | {{main|Transfusion-associated graft versus host disease}} | ||
This type of GvHD is associated with [[Blood_transfusion|transfusion]] of un-irradiated blood to immunocompromised recipients. It can also occur in situations where the blood donor is [[homozygous]] and the recipient is [[heterozygous]] for an [[Human leukocyte antigen|HLA]] [[haplotype]]. It is associated with higher mortality (80-90%) due to involvement of bone marrow lymphoid tissue, however the clinical manifestations are similar to GVHD resulting from bone marrow transplantation. Transfusion-associated GvHD is rare in modern medicine. It is almost entirely preventable by controlled irradiation of blood products to inactivate the white blood cells (including lymphocytes) within. | *This type of GvHD is associated with [[Blood_transfusion|transfusion]] of un-irradiated blood to immunocompromised recipients. It can also occur in situations where the blood donor is [[homozygous]] and the recipient is [[heterozygous]] for an [[Human leukocyte antigen|HLA]] [[haplotype]]. It is associated with higher mortality (80-90%) due to involvement of bone marrow lymphoid tissue, however the clinical manifestations are similar to GVHD resulting from bone marrow transplantation. Transfusion-associated GvHD is rare in modern medicine. It is almost entirely preventable by controlled irradiation of blood products to inactivate the white blood cells (including lymphocytes) within. | ||
==References== | ==References== | ||
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{{WH}} | {{WH}} | ||
[[Category:Hematology]] | [[Category:Hematology]] | ||
[[Category:Immunology]] | [[Category:Immunology]] | ||
Latest revision as of 21:55, 29 July 2020
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Graft-versus-host disease |
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Differentiating Graft-versus-host disease from other Diseases |
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Diagnosis |
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Treatment |
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Graft-versus-host disease classification On the Web |
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American Roentgen Ray Society Images of Graft-versus-host disease classification |
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Risk calculators and risk factors for Graft-versus-host disease classification |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Shyam Patel [2]
Overview
Classification can be related to time-of-onset or to disease severity. Time-of-onset classification divides GvHD into acute or chronic, based on the key time point of 100 days. Severity classification divides GvHD into stages and grades, as defined by the International Bone Marrow Transplant Registry (IBMTR). The ultimate grade of GvHD is determined by the stages of the individual organs affected. Grade 1 GvHD, for example, is characterized by skin involvement but without liver or GI involvement.
Classification
- Clinically, graft-versus-host-disease is divided into acute and chronic forms.
- The acute or fulminant form of the disease (aGVHD) is normally observed within the first 100 days post-transplant[1], and is a major challenge to transplants owing to associated morbidity and mortality[2].
- The chronic form of graft-versus-host-disease (cGVHD) normally occurs after 100 days. The appearance of moderate to severe cases of cGvHD adversely influences long-term survival [3].
- The overlap syndrome includes features of both acute and chronic GvHD. This is less commonly encountered.[4]
- This distinction is not arbitrary: acute and chronic GvHD appear to involve different immune cell subsets, different cytokine profiles, somewhat different host targets, and respond differently to treatment.
- The severity classification is based on skin, liver, and GI involvement. The International Bone Marrow Transplant Registry (IBMTR) has created a staging and grading system.[5] In this classification, GvHD is divided as follows:
Skin:
- Stage 0: no rash
- Stage 1: maculopapular rash < 25% of body surface area
- Stage 2: maculopapular rash 25-50% of body surface area
- Stage 3: maculopapular rash >50% of body surface area
- Stage 4: generalized erythema plus bullous formation
Liver:
- Stage 0: bilirubin < 2 mg/dl
- Stage 1: bilirubin 2-3 mg/dl
- Stage 2: bilirubin 3.1-6 mg/dl
- Stage 3: bilirubin 6.1-15 mg/dl
- Stage 4: bilirubin >15 mg/dl
GI:
- Stage 0: < 50cc stool per day or persistent nausea
- Stage 1: 500-999cc stool per day
- Stage 2: 1000-1500cc stool per day
- Stage 3: > 1500cc stool per day
- Stage 4: severe abdominal pain or ileus
The conglomeration of staging gives rise to a grade. The grading system is as follows:
- Grade 1: skin stage 1-2 with no liver or GI involvement
- Grade 2: skin stage 3 or liver stage 1 or GI stage 1
- Grade 3: skin with any stage or liver stage 2-3 or GI stage 2-4
- Grade 4: skin stage 4 or liver stage 4 or GI with any stage
Transfusion-associated GVHD
- This type of GvHD is associated with transfusion of un-irradiated blood to immunocompromised recipients. It can also occur in situations where the blood donor is homozygous and the recipient is heterozygous for an HLA haplotype. It is associated with higher mortality (80-90%) due to involvement of bone marrow lymphoid tissue, however the clinical manifestations are similar to GVHD resulting from bone marrow transplantation. Transfusion-associated GvHD is rare in modern medicine. It is almost entirely preventable by controlled irradiation of blood products to inactivate the white blood cells (including lymphocytes) within.
References
- ↑ Graft versus Host Disease, from the National Marrow Donor Program
- ↑ Goker H, Haznedaroglu IC, Chao NJ (2001). "Acute graft-vs-host disease: pathobiology and management". Exp. Hematol. 29 (3): 259–77. PMID 11274753.
- ↑ Lee SJ, Vogelsang G, Flowers ME (2003). "Chronic graft-versus-host disease". Biol. Blood Marrow Transplant. 9 (4): 215–33. doi:10.1053/bbmt.2003.50026. PMID 12720215.
- ↑ 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.
- ↑ Qian L, Wu Z, Shen J (2013). "Advances in the treatment of acute graft-versus-host disease". J Cell Mol Med. 17 (8): 966–75. doi:10.1111/jcmm.12093. PMC 3780546. PMID 23802653.