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Chronic graft-versus-host disease in 52 patients: adverse natural course and successful treatment with combination immunosuppression

KM Sullivan, HM Shulman, R Storb, PL Weiden, RP Witherspoon, GB McDonald, MM Schubert, K Atkinson and ED Thomas

Fifty-two of 175 (30%) survivors of allogeneic marrow transplantation developed chronic graft-versus-hose diseases (GVHD). Five with limited chronic GVHD had an indolent clinical course with involvement of only the skin and liver. Forty-seven with extensive chronic GVHD had an unfavorable multiorgan disorder that resembled several autoimmune diseases. Thirteen patients with extensive disease (group I) were not treated and only 2 survive with Karnofsky scores >- 70%. Mortality resulted from infections and morbidity from sica syndrome, pulmonary and hepatic insufficiency, scleroderma-like skin disease, and contractures. Another 13 (group II) received a median of 8 mo prednisone and/or a brief course of antithymocyte globulin, and 3 survive without disability. The other 21 (group III) were treated with a combination of prednisone (1.0 mg/kg/q.o.d.) and either cyclophosphamide, procarbazine, or azathioprine (all 1.5 mg/kg/day) for a median of 13 mo. Combination therapy was well tolerated with only modest myelotoxicity. Fifteen in group III had a good and 4 a fair response to treatment while 2 with no response died. Azathioprine and prednisone was the most effective regimen. All therapy has been discontinued in 12 group III patients: GVHD returned in 5 (including 2 who died in spite of retreatment) while 7 remain free of GVHD for a median of 11 (range 6-30) mo observation. Only I group III survivor is disabled and 16 of the original 21 are alive 2-4 yr after transplant with Karnofsky scores of 70%-100%. Thus, combination immmunosuppression appears to favorably affect and, in some cases, premanently arrest the adverse natural course of extensive chronic GVHD.

Volume 57, Issue 2, pp. 267-276, 02/01/1981
Copyright © 1981 by The American Society of Hematology


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J. P. Dunn, D. A. Jabs, J. Wingard, C. Enger, G. Vogelsang, and G. Santos
Bone Marrow Transplantation and Cataract Development
Arch Ophthalmol, October 1, 1993; 111(10): 1367 - 1373.
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R. H. Fried, C. S. Murakami, L. D. Fisher, R. A. Willson, K. M. Sullivan, and G. B. McDonald
Ursodeoxycholic Acid Treatment of Refractory Chronic Graft-versus-Host Disease of the Liver
Ann Intern Med, April 15, 1992; 116(8): 624 - 629.
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Arch DermatolHome page
R. M. Jampel, E. R. Farmer, G. B. Vogelsang, J. Wingard, G. W. Santos, and W. L. Morison
PUVA Therapy for Chronic Cutaneous Graft-vs-Host Disease
Arch Dermatol, November 1, 1991; 127(11): 1673 - 1678.
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M. H. Sayegh, N. A. Fine, J. L. Smith, H. G. Rennke, E. L. Milford, and N. L. Tilney
Immunologic Tolerance to Renal Allografts after Bone Marrow Transplants from the Same Donors
Ann Intern Med, June 1, 1991; 114(11): 954 - 955.
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J. G. Clark, S. W. Crawford, D. K. Madtes, and K. M. Sullivan
Obstructive Lung Disease after Allogeneic Marrow Transplantation: Clinical Presentation and Course
Ann Intern Med, September 1, 1989; 111(5): 368 - 376.
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Arch OphthalmolHome page
D. A. Jabs, J. Wingard, W. R. Green, E. R. Farmer, G. Vogelsang, and R. Saral
The Eye in Bone Marrow Transplantation: III. Conjunctival Graft-vs-Host Disease
Arch Ophthalmol, September 1, 1989; 107(9): 1343 - 1348.
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P. Kalhs, S. Panzer, K. Kletter, E. Minar, M. Stain-Kos, R. Walter, K. Lechner, and W. Hinterberger
Functional Asplenia after Bone Marrow Transplantation: A Late Complication Related to Extensive Chronic Graft-Versus-Host Disease
Ann Intern Med, September 15, 1988; 109(6): 461 - 464.
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N. R. Howe and P. G. Lang
Squamous Cell Carcinoma of the Sole in a Patient With Chronic Graft-vs-Host Disease
Arch Dermatol, August 1, 1988; 124(8): 1244 - 1245.
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J. G. CLARK, D. A. SCHWARTZ, N. FLOURNOY, K. M. SULLIVAN, S. W. CRAWFORD, and E. D. THOMAS
Risk Factors for Airflow Obstruction in Recipients of Bone Marrow Transplants
Ann Intern Med, November 1, 1987; 107(5): 648 - 656.
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C. ANASETTI, K. C. DONEY, R. STORB, J. D. MEYERS, V. T. FAREWELL, C. D. BUCKNER, F. R. APPELBAUM, K. M. SULLIVAN, R. A. CLIFT, H. J. DEEG, et al.
Marrow Transplantation for Severe Aplastic Anemia: Long-Term Outcome in Fifty "Untransfused" Patients
Ann Intern Med, April 1, 1986; 104(4): 461 - 466.
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A. P. Barrett and A. M. Bilous
Oral Patterns of Acute and Chronic Graft-v-Host Disease
Arch Dermatol, November 1, 1984; 120(11): 1461 - 1465.
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Arch Intern MedHome page
M. M. Schubert, K. M. Sullivan, T. H. Morton, K. T. Izutsu, D. E. Peterson, N. Flournoy, E. L. Truelove, G. E. Sale, C. D. Buckner, R. Storb, et al.
Oral Manifestations of Chronic Graft-v-Host Disease
Arch Intern Med, August 1, 1984; 144(8): 1591 - 1595.
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W. D. James and R. B. Odom
Graft-v-Host Disease
Arch Dermatol, August 1, 1983; 119(8): 683 - 689.
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Arch OphthalmolHome page
M. K. Jack, G. M. Jack, G. E. Sale, H. M. Shulman, and K. M. Sullivan
Ocular Manifestations of Graft-v-Host Disease
Arch Ophthalmol, July 1, 1983; 101(7): 1080 - 1084.
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R. STORB, R. L. PRENTICE, K. M. SULLIVAN, H. M. SHULMAN, H. J. DEEG, K. C. DONEY, C. D. BUCKNER, R. A. CLIFT, R. P. WITHERSPOON, F. A. APPELBAUM, et al.
Predictive Factors in Chronic Graft-Versus-Host Disease in Patients with Aplastic Anemia Treated by Marrow Transplantation from HLA-Identical Siblings
Ann Intern Med, April 1, 1983; 98(4): 461 - 466.
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L. W. Hirst, D. A. Jabs, P. J. Tutschka, W. R. Green, and G. W. Santos
The Eye in Bone Marrow Transplantation: I. Clinical Study
Arch Ophthalmol, April 1, 1983; 101(4): 580 - 584.
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R. P. GALE, R. E. CHAMPLIN, S. A. FEIG, and J. H. FITCHEN
Aplastic Anemia: Biology and Treatment
Ann Intern Med, October 1, 1981; 95(4): 477 - 494.
[Abstract] [PDF]



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