Lecture: graft vs host disease (GVHD)

Today’s lecture centered on graft versus host disease (GVHD).  This can occur after stem cell transplantation, when the donor T lymphocyte cannot recognize the host’s antigens (most commonly on skin, gut and liver, but other organs like lung sometimes involved).

When the liver is involved, it is often associated with jaundice.  The severity of jaundice helps to determine the severity of the GVHD.  In acute GVHD, liver biopsy is not always necessary, particularly if there is concomitant GVHD of skin or gut which is biopsy proven.  It is important to exclude other, common diseases in this cohort, like sinusoidal obstruction syndrome, viral hepatitis and drug toxicity.  If biopsy is performed, a pauci-inflammatory picture is the hallmark of this disease.

Treatment comes in the form of immunosuppression, and may require steroids +/- a calcineurin inhibitor.  Treatment may last many months, and a response should be seen within several weeks.  A second line therapy is called extracorporeal photopheresis and results are mixed.  An adjunctive therapy is ursodiol, 12 mg/kg, which in research trials was shown to prevent the occurrence of moderate/severe GVHD.

For those that do not respond to treatment, the liver can go on to suffer from chronic GVHD.  A histologic hallmark of this condition is ductopenia.  Some cases of GVHD of the liver go on to liver failure, and liver transplantation is indicated.

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