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Risk factors for acute GvHD include: older recipients, older donors, male recipient of female SCT (4 risk with previous donor pregnancies), matched unrelated donors, haploidentical sibling donor. Defined as GvHD occurring within first 100d post-transplant (usually starts between day 7 and 28 post-transplant). Ranges from mild self-limiting condition to extensive disease (may be fatal). Characterised by fever, rash, abnormal LFTs, diarrhoea, suppression of engraftment and viral reactivation, particularly CMV.

Classified according to the Seattle system by a staging for each organ involved (skin, liver, gut) and overall clinical grading based on the organ staging.

Skin—involved in >90% cases. May be mild and unremarkable maculopapular rash (esp. palms of hands and soles of feet, but can affect any part of the body). In more severe cases, erythroderma and extensive desquamation and exfoliation can occur.

Liver—typical pattern of LFT abnormalities is intrahepatic cholestasis with 4 bilirubin and alkaline phosphatase (relative sparing of transaminases). Note: this picture often does not discriminate between other causes of post-transplant liver dysfunction (e.g. drugs, infection - particularly CMV and fungal).

Gut—may occasionally be only organ involved, with nausea, vomiting, diarrhoea. Stool appearance may be highly abnormal with mincemeat or redcurrant jelly stools or green coloration.

Diagnosis

• Perform skin biopsy—but do not delay treatment if strong clinical suspicion.

• Rectal biopsy may be helpful (to distinguish infective from pseudo-membranous colitis) but beware risk of bleeding and bacteraemia— perform only if it will alter management.

• Where GI symptoms are predominantly upper GI, gastroscopy with oesophageal, gastric and duodenal biopsies may be helpful (e.g. to distinguish between CMV and fungal oesophagitis and gastritis). Liver biopsy is hazardous and should only be performed where other convincing diagnostic guides are not available. It should be performed only by the transjugular route by an experienced operator and covered appropriately with blood products.

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