Chronic GVHD

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Screening Liver for Chronic GVHD

Below are clinical manifestations that are potential early indicators of chronic GVHD of the liver. If GVHD is suspected, timely collaboration with the patient’s transplant center is recommended to confirm the diagnosis and to develop and evaluate a treatment plan.

These guidelines are based on published diagnostic criteria from the National Institutes of Health (NIH) Consensus Development Project on chronic GVHD. [1,2,3]

Clinical Examination

 
  • Assess for hepatomegaly and right upper quadrant abdominal tenderness
 

Diagnostic Testing

 
  • Total and direct bilirubin
  • Alkaline phosphatase (ALP)
  • Alanine aminotransferase (ALT)
  • Aspartate aminotransferase (AST)
  • Gamma glutamyl transpeptidase (GGT)
  • 5' Nucleotidase (5'-NT)
  • Liver biopsy may be needed in the absence of GVHD in another organ
 

Patient-Reported Symptoms and Signs

 
  • Jaundice
  • Malaise
  • Itching
  • Fatigue
 

Possible Manifestations

 

Hepatitis***

Rise in serum alanine aminotransferase, > 2x upper limit of normal, with or without jaundice

Progressive Cholestatic Features***

The flow of bile from the liver is blocked; total bilirubin, alkaline phosphate > 2x upper limit of normal; elevated gamma-glutamyl transpeptidase, followed by jaundice


Notes

* Distinctive but insufficient alone to establish an unequivocal diagnosis of chronic GVHD without further testing or additional organ involvement

** Rare, controversial, or non-specific features of chronic GVHD

*** Common in both acute and chronic GVHD


References

  1. Jagasia MH, Greinix HT, Arora M, et al. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: I. The 2014 Response Criteria Working Group Report. Biol Blood Marrow Transplant. 2015; 21(3): 389-401.  
  2. Lee SJ, Wolff D, Kitko C, et al. Measuring therapeutic response in chronic graft-versus-host disease. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: IV. The 2014 Response Criteria Working Group Report. Biol Blood Marrow Transplant. 2015; 21(6): 984-999.  
  3. These guidelines have been developed by the National Marrow Donor Program® (NMDP)/Be The Match® in consultation with Sandra A. Mitchell, CRNP, MScN, AOCN; National Institutes of Health Clinical Center; and Steven Z. Pavletic, M.D.; National Cancer Institute, National Institutes of Health, Bethesda, Md. The information in this document does not represent the official position of the NIH or the U.S. Government.

Additional review from:

  • Dennis L. Confer, M.D., NMDP/Be The Match, Minneapolis, Minn.
  • Linda J. Burns, M.D., NMDP/Be The Match, Minneapolis, Minn. 
  • Madan Jagasia, M.D., Vanderbilt University Medical Center, Nashville, Tenn. 
  • Stephanie J. Lee, M.D., Fred Hutchinson Cancer Research Center, Seattle, Wash.

Text adapted from reports of the NIH Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease from Biology of Blood and Marrow Transplantation by American Society for Blood and Marrow Transplantation. Reproduced with permission of Elsevier, Inc.

Photo Credits

  • Photos/ Keratosis Pilaris; Lichen Planus-like; Hypopigmentation; Sclerosis; Erosion; Maculopapular: Maria L. Turner, M.D.; Edward W.Cowen, M.D.; Dermatology Branch, National Cancer Institute, NIH, Bethesda, Md.
  • Photos/ Poikiloderma; Morphea; Lichen Planus-like; Lichen Sclerosus-like; Hyperpigmentation; Sclerosis; Nail dystrophy; Alopecia; Edema: Edward W. Cowen, M.D.; Dermatology Branch, National Cancer Institute, NIH, Bethesda, Md.
  • Photos/ Lichen planus; Mucoceles; Erythema: Mark M. Schubert, D.D.S., M.S.D.; Fred Hutchinson Cancer Research Center, Seattle, Wash.
  • Photo/ Keratoconjunctivitis: Mary E.D. Flowers, M.D.; University of Washington, Seattle, Wash.
  • Photo/ Blepharitis: Janine A. Smith, M.D.; National Eye Institute, NIH, Bethesda, Md.

All photos used with permission.