How we diagnose and treat acute graft-versus-host disease after solid organ transplantation.

Acute graft-versus-host disease (GVHD) is a rare complication following solid organ transplantation (SOT) carrying high mortality. Caused by immunocompetent donor leukocytes within the transplanted organ which become activated against recipient tissues, GVHD typically develops 2-12 weeks following SOT and can affect the skin, gastrointestinal tract, liver, and bone marrow. Signs and symptoms are nonspecific and include a rash, nausea, appetite loss, diarrhea, and cytopenias. Pancytopenia from marrow-directed GVHD is the primary driver of mortality. The diagnosis of GVHD is often delayed but should be confirmed by biopsy of an affected organ. Evidence of donor chimerism in blood or marrow supports the diagnosis. When GVHD is diagnosed we initiate treatment with systemic corticosteroids. At that time, if GVHD only involves skin or oral mucosa we also decrease maintenance immunosuppression levels to allow the recipient to reject the donor immune cells. For GVHD involving the marrow we initiate an allogeneic hematopoietic cell donor search early. In this article, we describe three cases of GVHD after SOT, outline our approach to diagnosis and management, and then provide analysis of the three instructive cases.