Treatment Guidelines for Acute Graft-Versus-Host Disease Post Liver Transplantation

Initial Assessment and Diagnosis

The National Comprehensive Cancer Network recommends biopsy of affected organs to confirm the diagnosis and rule out other causes of aGVHD 2
Liver function tests should be routinely monitored for early detection of hepatic aGVHD, which is often asymptomatic 2

The National Comprehensive Cancer Network recommends systemic corticosteroids as the first-line therapy for acute graft-versus-host disease, with methylprednisolone at 1-2 mg/kg/day as the initial treatment 1
For Grade I aGVHD, the National Comprehensive Cancer Network recommends continuing or restarting the original immunosuppressive agent 1
For Grade I aGVHD, medium to high-potency topical steroid formulations are recommended for body, with low-potency hydrocortisone for facial application 1, 3
The National Comprehensive Cancer Network recommends antihistamines for symptomatic relief of itching 1
For Grade II-IV aGVHD, systemic corticosteroids are the standard first-line treatment, with methylprednisolone 0.5-1 mg/kg/day for Grade II and 1-2 mg/kg/day for Grade III-IV 1
The original immunosuppressive agent should be restarted, continued, or escalated 1
For upper GI symptoms, the National Comprehensive Cancer Network recommends adding GI topical steroids 1

For patients who fail to respond to first-line therapy, the National Comprehensive Cancer Network recommends second-line options such as anti-thymocyte globulin (ATG) 1, 4
Thymoglobulin (rabbit ATG) can be used at 2.5 mg/kg/day for 4-6 consecutive days 4
ATGAM (horse ATG) can be used at 15 mg/kg twice daily for 5 days 4
Calcineurin inhibitors (tacrolimus, cyclosporine) can be used as second-line therapy 4, 5
Basiliximab (IL-2 receptor antagonist) can be used at 20 mg on days 1 and 4 4
Etanercept can be used at 25 mg twice weekly for 4 weeks, then 25 mg weekly for 4 weeks 5

Skin aGVHD tends to be more responsive to treatment than GI or liver aGVHD 4
For patients with progressive or worsening aGVHD despite multiple lines of therapy, enrollment in clinical trials should be considered 1

The National Comprehensive Cancer Network recommends grading aGVHD severity using modified Glucksberg criteria 2
First-line therapy should be initiated based on grade, with topical therapy for Grade I and systemic corticosteroids for Grade II-IV 1, 2