Inside the Clinic: Acute Graft-versus-Host Disease - Episode 3
Yi-Bin A. Chen, MD: That’s part of the progress we hope to make—being able to risk stratify patients and apply different treatments. And that’s a big problem in why we think trials have not succeeded in the past. At Massachusetts General Hospital, we talk about acute graft-vs-host disease [GVHD] a lot. It impacts us because it’s a rather early complication, and any time we have a patient who, unfortunately, dies of its complications, it truly hits home. We view home as the entire care team, especially because of how early it occurs and how much time they spend with us in and outside the hospital.
As part of our quality operations in our transplant program, we do analyze the incidence of acute graft-vs-host disease to understand what we’re seeing, and we compare it with what is being published. Having just reviewed our data over the last 2 years, we can say that the incidence of grades 2 through 4 acute GVHD—which are the grades that we truly care about the most because they have been shown to affect patient outcomes—occur in about 25% to 30% of our transplant patients. Severe graft-vs-host disease is regarded as grades 3 or 4 clinically, and that happens only in about 5% to 10% of our patients, thankfully. Yet for those 5% to 10%, so much progress remains. When we look at graft-vs-host disease, not every patient has the same risk. Zack, could you review some of the risk factors we think about when we think about a patient and their risk for developing acute GVHD?
Zachariah M. DeFilipp, MD: There are a number of established clinical risk factors for acute graft-vs-host disease that we have to think about when a patient is preparing for transplant. One of the most important factors is the degree of HLA [human leukocyte antigen] disparity between the donor and the recipient. Patients who are going to receive a transplant from a donor that is mismatched at HLA markers is more likely to develop acute graft-vs-host disease as compared with a donor who has a full match. Another donor-related factor to consider is the disparity of the gender between the donor and the recipient. As previous studies have shown, if a man patient receives cells from a woman patient there is a slightly increased risk for graft-vs-host disease as compared with other combinations of gender between the donor and the recipient.
Another important transplant factor is the conditioning regimen and intensity, which refers to the chemotherapy and/or radiation that a patient may receive prior to the infusion of the cells. It has been shown that patients who get higher doses of total-body irradiation [TBI] have an increased risk for graft-vs-host disease. The GVHD prophylaxis regimen that they receive also contributes to their GVHD risk. We talked about a number of these factors, and it’s always an overarching goal that when we create a plan for a patient, we try to minimize the risk for acute graft-vs-host disease. But at the same time, we have to remember that there are other patient- and disease-related factors that help influence our choice when it comes to these decisions.
Transcript Edited for Clarity