Chronic graft-versus-host disease: where is promise for the future?

Clinical laboratory markers of inflammation as determinants of chronic graft-versus-host disease activity and NIH global severity

Chronic graft versus host disease (cGVHD) remains a major cause of non-relapse morbidity and mortality after allogeneic hematopoietic stem cell transplantation. Currently there are no accepted measures of cGVHD activity to aid in clinical management and disease staging. We analyzed clinical markers of inflammation in the sera of patients with established cGVHD and correlated those with definitions of disease activity. 189 adults with cGVHD (33% moderate and 66% severe according to NIH global scoring) were consecutively enrolled onto a cross-sectional prospective cGVHD natural history study. At the time of evaluation, 80% were receiving systemic immunosuppression and failed a median of 4 prior systemic therapies (PST) for their cGVHD. Lower albumin (p<0.0001), higher CRP (C-reactive protein; p=0.043), higher platelets (p=0.030) and higher number of PST (p<0.0001) were associated with active disease defined as clinician's intention to intensify or alter systemic therapy due to the lack of response. Higher platelet count (p=0.021) and higher number of PST (p<0.0001) were associated with more severe diseased defined by NIH global score. This study identified common laboratory indicators of inflammation that can serve as markers of cGVHD activity and severity.

Mesenchymal stromal cells for graft-versus-host disease

Mesenchymal stromal cells (MSCs) have been shown to mediate immune responses in vitro and in vivo. These observations have led to clinical trials of MSC administration to ameliorate acute graft-versus-host disease (GVHD), the most serious complication arising after allogeneic hematopoietic cell transplantation. Clinical data suggest a benefit in approximately two-thirds of patients with steroid-resistant acute GVHD. Preliminary studies have been reported on the use of MSCs to treat de novo acute GVHD, for prophylaxis of the condition, and more recently, in the management of chronic GVHD. Although preclinical data inferred a possible role of MSCs in affecting GVHD mechanisms, more robust animal models became available only after numerous clinical trials with these cells had been undertaken. Further clinical trials, the development of more appropriate animal models and an effective means of tracking and imaging the introduced cells in real time in patients, are required to better define their role in this important area of medicine.

Early onset of acute GVHD indicates worse outcome in terms of severity of chronic GVHD compared with late onset

Acute GVHD (aGVHD) is an important risk factor for predicting the incidence or severity of chronic GVHD (cGVHD). Transplant outcome can be influenced by the onset time of aGVHD in patients who have received allogeneic PBSC transplants (PBSCTs). The medical records of 134 patients who survived more than 3 months after myeloablative allogeneic PBSCT were retrospectively reviewed. In all, 38 patients (28.4%) developed grade II-IV aGVHD before day +28 (early aGVHD) and 25 patients (18.7%) after day +28 (late aGVHD). The 5-year cumulative incidence of cGVHD was 78.9% in the early-aGVHD group and 56.6% in the late-aGVHD group (P=0.034). The 5-year OS was 51.0% for the early-aGVHD and 80.8% for the late-aGVHD group (P=0.406). Infection was the primary cause of death for the early-aGVHD group (51.4 vs 16.7%, P=0.017), whereas relapse of the primary disease was higher among the patients with late aGVHD, although this was statistically insignificant (58.3 vs 25.7%, P=0.309). In a multivariate analysis, early aGVHD was identified as a risk factor for developing cGVHD (hazard ratio (HR) 2.278, P=0.004). The development of aGVHD early after allogeneic PBSCT increased the risk of cGVHD and infection-related death rate when compared with the late onset of aGVHD.

Cutaneous graft-versus-host disease: a guide for the dermatologist

Graft-versus-host disease (GVHD) is defined by the aggregation of clinical and pathological manifestations in a recipient of allogeneic stem cells or bone marrow transplantation in which specific immunological as well as nonspecific phenomena lead to characteristic features. GVHD is one of the major complications after hematopoietic stem cell transplantations and responsible for posttherapeutic morbidity, mortality and decrease in quality of life of those patients. GVHD is critically induced and maintained by donor immunocompetent cells that particularly attack epithelia of fast proliferating tissues such as those from the liver, gastrointestinal tract and skin. On the basis of the time of presentation, cutaneous GVHD has been originally divided into an acute and chronic disease. The latter has traditionally been further subclassified into a more epithelial or lichenoid and a predominantly dermal or sclerodermoid form. With respect to the growing importance of this therapeutic procedure and increasing numbers of outpatients presenting with chronic GVHD, this article summarizes the updated knowledge on this disease focused for the dermatologist, and additionally it emphasizes the recent consensus documents on the various aspects of chronic GVHD of the National Institute of Health.

The changing face of graft-versus-host disease

Despite advances in the procedure and posttransplantation immunosuppressive therapy, more than half of allogeneic hematopoietic stem cell transplant (HSCT) recipients develop graft-versus-host disease (GVHD), which remains a major cause of morbidity and mortality. Modern HSCT protocols have resulted in substantial alterations in the timing and relative incidences of acute and chronic GVHD, making traditional classification schemes obsolete. This article reviews major changes in HSCT during the past decade, evolving concepts of acute and chronic GVHD (including new diagnostic criteria) and the expanding spectrum of cutaneous GVHD. It focuses on observations that have led to a better delineation of the full constellation of skin findings in chronic cutaneous GVHD, including lichen sclerosus, morpheaform lesions, and eosinophilic fasciitis. Recent insights into pathogenesis of GVHD, lessons from GVHD arising in settings outside HSCT, and therapeutic advances also are highlighted.

Chronic graft-versus-host disease

PURPOSE OF REVIEW

Chronic graft-versus-host disease is an important cause of late morbidity and mortality after allogeneic stem cell transplantation. With the renewed interest in its pathophysiology and treatment, this review discusses recent clinical and laboratory advances in this disease. Advances in pathophysiology, the relationship between chronic graft-versus-host disease and relapse incidence, and recent developments in the prophylaxis, initial therapy, and therapy for refractory disease are discussed.

RECENT FINDINGS

A better understanding of the pathophysiology of chronic graft-versus-host disease, including the potential role of a coordinated B-cell and T-cell response, is demonstrated. Corticosteroids and cyclosporine or tacrolimus remain the standard as initial therapy. This combination is effective in the majority of affected patients, although therapy is often required for longer than 1 year. Although no strategy has been demonstrated to be effective in specifically preventing chronic graft-versus-host disease, several drugs have recently been demonstrated to be effective therapeutic agents for steroid-refractory disease. Agents such as mycophenolate mofetil, sirolimus, and rituximab have demonstrated response rates of greater than 60% in patients with steroid-refractory disease.

SUMMARY

Renewed interest and understanding of chronic graft-versus-host disease have led to novel treatment strategies for steroid-refractory disease. A focus on the initial therapy and prophylaxis against chronic graft-versus-host disease is now warranted.