Approach to the Critical Patient

Immediate priorities

Life-threatening GVHD presentations

Concurrent threats requiring parallel management

Monitoring and targets

Hemodynamic and fluid monitoring

GVHD organ response monitoring

Consult triggers

Mandatory early consultations

History

Transplant context

Transplant details

Symptom onset and characterization

Timing of symptom onset

Skin symptoms

Gastrointestinal symptoms

Hepatic symptoms

Risk factors

Transplant-related risk factors

Patient-related risk factors

Medication history

Current immunosuppression compliance

Infection prophylaxis review

Physical Exam

Vitals and hemodynamic assessment

Vital sign pattern

Skin exam

Rash characterization

Oral mucosa

Abdominal exam

Gastrointestinal examination

Hepatic assessment

General and performance status

Performance status assessment

Differential Diagnosis

Close mimics of skin GVHD

Drug hypersensitivity reaction

Viral exanthem

Engraftment syndrome

Close mimics of GI GVHD

CMV colitis

Clostridioides difficile infection

Infectious enterocolitis

Close mimics of hepatic GVHD

Sinusoidal obstruction syndrome (SOS/VOD)

Drug-induced liver injury

Thrombotic microangiopathy (TMA)

Laboratory Tests

Core diagnostic labs

Complete blood count with differential

Comprehensive metabolic panel

Infection workup

Stool studies

Systemic viral surveillance

Immunosuppression monitoring

Calcineurin inhibitor levels

Glucose monitoring

Biomarkers

Ann Arbor aGVHD biomarker panel

Additional inflammatory markers

Diagnostic Tests

Scoring Systems

Glucksberg grading system

Overall grade (I to IV)

MAGIC criteria (refined grading)

MRI

MRI abdomen indications

MRCP consideration

CT

CT abdomen and pelvis

CT chest

Ultrasound

Abdominal ultrasound

POCUS applications

Disposition

Admission criteria

Inpatient admission indications

ICU-level indications

Outpatient management

Grade I to II outpatient criteria

Discharge planning

Treatment

Initial stabilization

Supportive measures

Grade I GVHD treatment

Topical therapy

Systemic immunosuppression

Grade II to IV GVHD systemic treatment

First-line systemic corticosteroids

Baseline immunosuppression escalation

Steroid-refractory GVHD treatment

Definition of steroid-refractory aGVHD

Ruxolitinib (JAK1/JAK2 inhibitor)

Alternative steroid-refractory agents

Remestemcel-L (pediatric indication)

FDA-approved for steroid-refractory aGVHD in patients >= 2 months

Supportive care

Infection prophylaxis on corticosteroids

GI symptom management

Steroid side effect prevention

Special Populations

Pregnancy

Pregnancy context for GVHD

Medication safety in pregnancy

Obstetric considerations

Geriatric

Atypical presentations in older adults

Medication considerations

Disposition bias toward inpatient management

Pediatrics

Epidemiology and risk in pediatric alloHCT

Treatment differences in children

Supportive care in children

Background

Epidemiology

Incidence and prevalence

Distribution by organ

Pathophysiology

Phase 1: tissue damage and danger signals

Phase 2: donor T cell activation

Phase 3: target organ destruction

Role of microbiome

Therapeutic Considerations

Steroid pharmacology rationale

Ruxolitinib mechanism

Biomarker-guided therapy

Prevention strategies

Patient Discharge Instructions

copy discharge instructions

Graft versus host disease home care instructions

Warning signs requiring immediate return to emergency department

Follow-up schedule

References

Guidelines and key sources

Primary guidelines

Landmark trials and reviews

Epidemiology and grading references

Biomarker and diagnostic references

Coding references