Graft versus host disease

Because treatment of graft versus host disease (GVHD) involves the use of aggressive, multimodal, immunosuppressive regimens that can quickly lead to potentially life-threatening complications, close monitoring is essential to allow early recognition and intervention, and to optimize the overall care delivered to patients.

The frequency of monitoring and follow-up in the outpatient setting can range between once weekly to daily. Diagnosis of GVHD is based on clinical manifestations; therefore, follow-up should include regular and repeated physical exam, covering all relevant organ systems, and interval history.

Recommendations regarding monitoring, and ancillary and supportive therapies, have been published.​​​[80]Rotz SJ, Bhatt NS, Hamilton BK, et al. International recommendations for screening and preventative practices for onlg-term survivors of transplantation and cellular therapy: a 2023 update. Transplant Cell Ther. 2024 Apr;30(4):349-85. https://pmc.ncbi.nlm.nih.gov/articles/PMC11181337 http://www.ncbi.nlm.nih.gov/pubmed/38413247?tool=bestpractice.com [82]Children's Oncology Group. Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers, Version 6.0. Oct 2023 [internet publication]. http://www.survivorshipguidelines.org ​​[169]Carpenter PA, Kitko CL, Elad S, et al. National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: V. The 2014 Ancillary Therapy and Supportive Care Working Group report. Biol Blood Marrow Transplant. 2015 Jul;21(7):1167-87. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821166 http://www.ncbi.nlm.nih.gov/pubmed/25838185?tool=bestpractice.com ​​​​​​[178]National Marrow Donor Program. Post-transplant care guideline: long-term care recommendations. 2023 [internet publication]. https://network.nmdp.org/-/media/project/nmdp/networkresourcecenter/pdfs/services-support/hematology-oncology/post-transplant-care/np23070-posttransplantcareguidelines-11x85-2024-08-27-digitalversion.pdf?rev=becc1a5035cd4723ae097805cf5599da&hash=17E46BBDAA99FE0AD90E8804BF95FCD1

The NIH recommends that all organ systems potentially affected by chronic GVHD or its treatment should be monitored serially in individuals at risk at least annually for 5 years after hematopoietic cell transplantation (HCT).[169]Carpenter PA, Kitko CL, Elad S, et al. National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: V. The 2014 Ancillary Therapy and Supportive Care Working Group report. Biol Blood Marrow Transplant. 2015 Jul;21(7):1167-87. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821166 http://www.ncbi.nlm.nih.gov/pubmed/25838185?tool=bestpractice.com Scope and frequency of monitoring should be individualized as clinically indicated, with more frequent monitoring strongly advised for those with active GVHD, especially during high-risk periods (e.g., treatment taper or escalation), and for those who are participating in clinical trials.[169]Carpenter PA, Kitko CL, Elad S, et al. National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: V. The 2014 Ancillary Therapy and Supportive Care Working Group report. Biol Blood Marrow Transplant. 2015 Jul;21(7):1167-87. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821166 http://www.ncbi.nlm.nih.gov/pubmed/25838185?tool=bestpractice.com

Specific NIH recommendations include:[169]Carpenter PA, Kitko CL, Elad S, et al. National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: V. The 2014 Ancillary Therapy and Supportive Care Working Group report. Biol Blood Marrow Transplant. 2015 Jul;21(7):1167-87. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821166 http://www.ncbi.nlm.nih.gov/pubmed/25838185?tool=bestpractice.com

• Interval history with symptom assessment (including psychosocial symptoms) and a drug medication review (minimal every 3 months)

• Physical exam (minimal every 3 months)

  • Weight (adults: every 3 months; children: every 1-3 months)

  • Height (adults: every 12 months; children and adolescents: every 3-6 months)

  • Nutritional assessment (adults: every 3-6 months; children: every 1-6 months)

  • Tanner staging sexual maturity score (children and adolescents: every 6-12 months)

  • Developmental assessment (children and adolescents: every 3-6 months)

• Laboratory monitoring

  • Complete blood cell counts with differential (every 3 months)

  • Chemistry panel including renal and liver function tests (every 3 months)

  • Therapeutic drug monitoring (every 3 months)

  • IgG level (every 1-3 months until normal and independent of replacement)

  • Lipid profile (every 6 months during treatment with corticosteroids or sirolimus)

  • Iron indices (every 6-12 months if red blood cell transfusions are required or if iron overload has been documented previously)

  • Pulmonary function tests (every 3-6 months)

  • Endocrine function evaluation, for example, thyroid function tests, bone densitometry, calcium levels, 25-OH vitamin D (every 12 months).

• Subspecialty evaluations

  • Ophthalmology (every 3-12 months)

  • Dental evaluation and oral cancer surveillance with comprehensive soft and hard tissue exam (radiographs as indicated), culture, biopsy, or photographs of lesions (as clinically indicated), and professional dental hygiene (every 6 months)

  • Dermatology with assessment of extent and type of skin involvement, biopsy, or photographs (as clinically indicated)

  • Gynecology for vulvar or vaginal involvement (as clinically indicated)

  • Physiotherapy with assessment of range of motion (every 3-12 months if sclerotic features are present)

  • Neuropsychologic testing (every 12 months as clinically indicated)