Methods for Assessing Acute GVHD

Aaron C. Logan, MD, PhD:Acute graft-versus-host disease [GVHD] is an unfortunate complication of allogeneic transplant that stems from reaction of the donor immune cells against the recipient’s body. Even in this day and age, it’s quite a problem for our patient population, with anywhere between 30% and 50% of patients experiencing acute GVHD depending on the specific circumstances of their type of transplant and their type of donor.

The way we look at acute GVHD is by staging the organs that are affected. The 3 organs that are principally affected by acute GVHD are the skin, liver, and gut. With the skin, it can be anything from a mild localized rash to full body redness, or erythema. Even blistering of the skin can happen in the most severe cases.

When GVHD affects the liver, it usually leads to elevation of the liver enzymes. That’s used for staging liver GVHD—bilirubin elevation. And when GVHD affects the gut, if it affects the upper GI [gastrointestinal] tract, it will manifest as anorexia, nausea, vomiting, weight loss, things like that. When it affects the lower GI tract, which it does more commonly, it is associated with a secretory diarrhea, which we actually stage based on the volume of diarrhea output that the patient experiences.

So for the 3 organs of involvement, we come up with a stage, and then we come with an aggregate grade for the patient’s acute GVHD. Based on the grade of acute GVHD, we then determine what the appropriate therapy should be.

The MAGIC [Mount Sinai Acute GvHD International Consortium] grading schema for acute GVHD is an adaptation from the original Glucksberg grading scale, still implementing staging for skin, liver, and gut—with gut being separated between upper GI and lower GI—and also having a system for taking the stage of each organ of involvement and coming up with an aggregate grade. That is now being utilized in most clinical trials and in clinical practice at most transplant centers that are engaged in assessing GVHD in their patients.

The standardization of the grading scale has been something that’s been very important, to try and standardize how we’re assessing GVHD in different centers so that we’re hopefully making similar decisions about when we’re implementing therapies such as high-dose corticosteroids, or now, alternative agents for steroid-refractory or steroid-dependent graft-versus-host disease.

Transcript edited for clarity.