The Nature of Acute and Chronic GvHD

Yi-Bin Chen, MD: Graft-versus-host disease remains a major complication and challenge for patients and for us as transplant practitioners as well. Inherent to the mechanism of why transplant works is what we believe to be an immunological attack on malignancy by donor cells. The risk that comes with that is graft-versus-host disease because patients and donors are different. Even though we obviously try to match very closely, these are different people and there’s always a risk of graft-versus-host disease.

Simply, graft-versus-host disease is when the donor’s white blood cells attack the recipient’s healthy body, and transplant is probably the only setting that we will see this disease in. There are two general types of graft-versus-host disease, classified as acute and chronic. Acute graft-versus-host disease generally happens in the first few months after transplant. This is the time most vulnerable for our patients. They’ve often spent several weeks in the hospital already and they’re emerging at a time when they’re quite weakened. They’re recovering from infections and other complications. If graft-versus-host disease were to happen at that point, it often requires another hospitalization. It’s very difficult medically, emotionally, and physically for our patients to overcome. Chronic graft-versus-host disease generally happens later. In our large series of survivors after transplant, it’s the single most important factor that determines overall quality of life in the long run. As we look to the future of transplant and more survivors, fortunately, chronic graft-versus-host disease is a huge unmet need for us because we do want to maintain their long-term quality of life.

Zachariah DeFilipp, MD: Graft-versus-host disease is a clinical syndrome that most generally is divided into acute and chronic forms. Historically, the distinction between the acute form and the chronic form was made based on a time mark of 100 days after transplant.

We now know that these two entities, the acute and chronic graft-versus-host disease, are distinct in their clinical presentation as well as in their biology. Acute graft-versus-host disease typically presents earlier on after the transplant and clinically, it manifests in a few cardinal manifestations: a skin rash, diarrhea, nausea, and inflammation of the liver.

Chronic graft-versus-host disease typically presents later on after the transplant and can affect a large number of different organ systems, including the eyes, the mouth, the GI [gastrointestinal] tract, the lungs, the liver, soft tissues, and others.

Usually at its initial presentation it has more of an inflammatory nature, but in more advanced cases we often see a more fibrotic nature, such as is seen in patients who have systemic sclerosis.

Transcript Edited for Clarity