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Upper GI acute GvHD adds minimal prognostic value
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2005-2008
2009-2012
cGVHD incidence
aGvHD Therapy-related steroid use Topical steroids +/- other agents Systemic steroids +/- other agents
1192 (35) 687 (20) 1283 (37)
0
0
478 (36) 284 (21) 676 (50)
216 (16)
956 (71)
478 (39) 215 (18) 660 (55)
46 (4)
1094 (90)
106 (46) 58 (25) 127 (55)
7 (3)
207 (90)
575 (37) 221 (14) 533 (34)
15 (1)
1476 (96)
N.B.,for each set of comparisons,demographics were compared and significant differences that affected a particular outcome were addressed via the respective statistical mod- els. aGvHD: acute graft-versus-host disease; cGvHD: chronic graft-versus-host disease D: donor; R: recipient; M: male; F: female; CMV: cytomegalovirus; UGI: upper gastrointestinal; AML: acute myelogenous leukemia; ALL: acute lymphoblastic leukemia; CML: chronic myelogenous leukemia; MDS: myelodysplastic syndrome; HLA: human leukocyte antigen; URD: unrelated donor; TBI: total-body irradiation; MMF: mycophenolate mofetil; HSCT: hematopoietic stem cell transplant.
Table 3A. Clinical outcomes in patients with aGvHD: pairwise comparisons between isolated UGI aGvHD versus aGvHD without UGI symptoms.
Overall Survival HR Isolated UGI (baseline) 1.00 Grade I 0.78 Grade II 0.95 Grades III/IV 2.06
Disease-free Survival
Isolated UGI (baseline) 1.00 Grade I 0.81 Grade II 0.93 Grades III/IV 1.66
Relapse
Isolated UGI (baseline) 1.00 Grade I 0.84 Grade II 0.89 Grades III/IV 0.94
Treatment-related Mortality
Isolated UGI (baseline) 1.00 Grade I 0.83 Grade II 1.14 Grades III/IV 3.39
Matched Related Donor
95% CI P
0.56-1.10 0.16
0.67-1.35 0.77
1.48-2.88 <0.0001
0.59-1.11 0.19
0.67-1.28 0.67
1.22-2.28 0.0015
0.58-1.22 0.37 0.60-1.30 0.54 0.64-1.39 0.77
0.45-1.54 0.55
0.61-2.13 0.69
1.87-6.16 <0.0001
Unrelated Donor
HR 95% CI P 1.00
0.89 0.68-1.15 0.37 1.12 0.87-1.45 0.38
2.28 1.77-2.92
1.00
0.74 0.57-0.94
0.94 0.74-1.20 0.63
<0.0001
0.016
1.66 1.31-2.11
1.00
0.74 0.55-0.99
<0.0001
0.045
0.85 0.64-1.14 0.28 0.86 0.64-1.16 0.33
1.00
0.93 0.58-1.52 0.78 1.43 0.90-2.27 0.13
Chronic GvHD
Isolated UGI (baseline) 1.00
Grade I 1.16 0.83-1.67 0.38 Grade II 1.22 0.85-1.72 0.28 Grades III/IV 1.09 0.76-1.56 0.65
3.91 2.5-6.14
1.00
1.37 1.06-1.79
1.59 1.22-2.04
1.67 1.29-2.17
<0.0001
0.016
0.0004
0.0001
Bold values indicate significance at P-value <0.01. Italicized values indicate 0.1< P-value <0.05. aGvHD: acute graft-versus-host disease; UGI: upper gastrointestinal.
aGVHD did not affect development of cGVHD or sur- vival.21 Second, other studies have found that the vast majority of patients with symptoms prompting a GI eval- uation will have diffuse intestinal involvement, suggesting that symptom-directed upper endoscopy may not be nec- essary.22-24 Third, the reliance on biopsy confirmation in the diagnosis and reporting of UGI aGvHD varies widely, and currently the diagnosis and reporting is often based on relatively non-specific symptoms. Lastly, GvHD-related mortality and patterns of therapy in general have changed over the past two decades.25
We conducted a systematic analysis to determine: 1) the prognostic impact of isolated UGI (iUGI) aGvHD and thus verify the position of this manifestation in the
Consensus grading scheme when present alone, and 2) if UGI symptoms add prognostic value when present in addition to skin, LGI or hepatic aGvHD. We hypothe- sized that as currently diagnosed, reported and treated, the impact of UGI aGvHD on transplant-related outcomes would be less than initially reported.
Methods
All patients provided informed consent to the Center for International Blood and Marrow Transplant Research (CIBMTR) research program. This study was approved by the Institutional Review Board of the National Marrow Donor Program.
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