From the Guidelines
Engraftment syndrome and graft versus host disease (GVHD) are distinct complications of stem cell transplantation with different timing, mechanisms, and treatments. The key differences between engraftment syndrome and GVHD lie in their timing, pathophysiology, and clinical manifestations. Engraftment syndrome typically occurs within 7-14 days post-transplant, coinciding with neutrophil recovery, and represents an inflammatory response to the engrafting cells, manifesting as fever, rash, pulmonary edema, weight gain, and liver dysfunction 1. In contrast, GVHD develops later, with acute GVHD occurring within 100 days and chronic GVHD beyond 100 days, resulting from donor T-cells attacking recipient tissues, primarily affecting the skin, gastrointestinal tract, and liver, with chronic GVHD potentially involving multiple organ systems 1.
Treatment Approaches
Treatment approaches for these two conditions differ significantly. Engraftment syndrome typically responds well to short courses of corticosteroids, such as methylprednisolone at 1-2 mg/kg/day for 3-7 days 1. On the other hand, GVHD requires more prolonged immunosuppression, often with higher-dose steroids (methylprednisolone 2 mg/kg/day) and additional agents like calcineurin inhibitors, antithymocyte globulin, or newer biologics 1. The choice of treatment is guided by the severity of the disease and the patient's overall condition, with the goal of minimizing morbidity, mortality, and impact on quality of life.
Prognosis and Impact
The prognosis and impact on quality of life also vary between engraftment syndrome and GVHD. Engraftment syndrome is generally self-limiting with a good prognosis, whereas GVHD can become chronic and life-threatening, significantly impacting transplant outcomes and quality of life 1. The management of GVHD, including the use of systemic immunosuppression and the treatment of corticosteroid-refractory GVHD with therapies such as cyclophosphamide, biologics, and photopheresis, underscores the complexity and potential severity of this condition 1.
Clinical Considerations
In clinical practice, distinguishing between engraftment syndrome and GVHD is crucial for appropriate management and to improve patient outcomes. This distinction, along with an understanding of the timing, mechanisms, and treatment approaches for each condition, is essential for healthcare providers to make informed decisions that prioritize morbidity, mortality, and quality of life. Given the potential for significant morbidity and mortality associated with GVHD, a proactive and aggressive approach to its prevention and treatment, including the use of reduced intensity conditioning regimens and post-transplant cyclophosphamide for GVHD prophylaxis, is warranted in high-risk patients 1.
From the Research
Difference between Engraftment Syndrome and Graft vs Host Disease (GVHD)
- Engraftment syndrome is not explicitly defined in the provided studies, but it can be inferred as a condition that occurs after hematopoietic stem cell transplantation, characterized by a vigorous fluctuation of soluble interleukin 2 receptor levels in the serum after engraftment, which is highly related to the occurrence of chronic GVHD 2.
- Graft vs Host Disease (GVHD) is a major complication that occurs after allogeneic hematopoietic stem cell transplantation (HSCT), characterized by an immunologically mediated disease that contributes substantially to transplant-related morbidity and mortality 3, 4.
- The key differences between engraftment syndrome and GVHD are:
- Engraftment syndrome is a condition that occurs after engraftment, while GVHD is a complication that occurs after HSCT.
- Engraftment syndrome is characterized by a fluctuation of soluble interleukin 2 receptor levels, while GVHD is characterized by an immunologically mediated disease.
- Engraftment syndrome is highly related to the occurrence of chronic GVHD, while GVHD can be acute or chronic.
GVHD Prophylaxis and Management
- The prophylaxis and management of GVHD have undergone significant changes in recent years, with the introduction of new drugs and updated clinical practice recommendations 5.
- The European Society for Blood and Marrow Transplantation (EBMT) has updated its clinical practice recommendations for the prophylaxis and management of GVHD, including the use of ruxolitinib in steroid-refractory acute GVHD and steroid-refractory chronic GVHD, and the use of rabbit anti-T-cell (thymocyte) globulin or post-transplantation cyclophosphamide as standard GVHD prophylaxis in peripheral blood stem-cell transplantations from unrelated donors 5.
- Mesenchymal stromal cells have also been used in the treatment of GVHD, particularly in steroid-refractory cases, due to their immunomodulatory activity and low levels of class 1 and no class 2 HLA antigens, making them immunoprivileged 6.