Commentary (Ezzone)-Graft-Versus-Host Disease: A Complex Long-Term Side Effect of Hematopoietic Stem Cell

Prophylaxis and management of graft-versus-host disease (GVHD) following a related or unrelated allogeneic hematopoietic stem cell transplant (HSCT) is very complex. The review article written by Barton-Burke and colleagues discusses all of the major components of the clinical manifestations, prophylaxis, and treatment of GVHD.

Over the years, a better understanding of GVHD has led to use of newer immunosuppressive medications and strategies to both prevent and treat this unique complication of allogeneic HSCT. The complexity of the mechanisms of GVHD is illustrated well in Figure 1. The case study at the beginning of the article provides an introduction to the clinical manifestations, prevention, and treatment of GVHD. The discussion of Mr. SR’s Medication Regimen for cGVHD is helpful to the understanding of medications commonly used to treat cGVHD. In both the case study and Table 1, some medications used for treatment of cGVHD are used in current practice but may be given at a different dosage and frequency. Other immunosuppressive agents for prevention or treatment of GVHD may also be used. For example, Prograf (tacrolimus) has often replaced the use of cyclosporine. Table 3, in listing commonly used immunsuppressive medications, is helpful in its description of the immunosuppressive effects of each medication and common adverse reactions. In the review article, a description of the clinical manifestations of GVHD is included. Table 2, “Clinical Manifestations of GVHD and Nursing Management,” provides a good review of signs and symptoms of acute and chronic GVHD as well as nursing management. The table presents helpful information about the multiorgan systems involved in patients with GVHD.

In the text of the article, the time frame in which acute and chronic GVHD usually occur is noted, as is the occurrence of GVHD following donor lymphocyte infusion (DLI). As the authors point out, the usual time frames for occurrence of acute GVHD (time of engraftment to 100 days post-tranplant) and chronic GVHD (after 100 days) have become complicated with the use of DLI. As they note, acute GVHD may occur initially following DLI, making it necessary to keep track of the “day” post transplant and the “day” post DLI.

The risk of infection in persons who develop GVHD is described. Common infection-preventive strategies are reviewed, including prophylactic medications and vaccinations. In addition, novel therapies such as photophoresis, PUVA, and extracorpeal photopheresis are briefly discussed.

Overall, this article is a valuable review of the clinical manifestations, prevention, and treatment of acute and chronic GVHD, and it provides useful background information about the basic principles of GVHD.

Financial Disclosure:The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.