Graft-versus-host disease - Treatment of steroid-resistant acute graft-versus-host disease with anti-thymocyte globulin

Acute graft-versus-host disease (aGVHD)) is a major cause of mortality afte r allogeneic stem cell transplantation. Although initial treatment with cor ticosteroids is effective in the majority of patients, 30-60% develop stero id resistance. Anti-thymocyte globulin (ATG) is commonly used as first-line therapy for steroid resistant (SR) aGVHD, However, data on its efficacy ar e limited. At two institutions we reviewed the results of treatment with AT G of 58 patients with SR aGVHD, Initial manifestations of aGVHD were treate d with 2 mg/kg/day of methylprednisolone (h IP). Equine ATG was administere d as first-line therapy for SR aGVHD, a median of 9 days (range, 3 to 39) a fter initiation of MP, At the time of initiation of ATG, IBMTR severity ind ices B, C and D were observed in 6%, 40% and 54% of patients, respectively. Improvement was observed in 30% of patients treated with ATG, Skin disease was more likely to improve with ATG (79%), while progression of gut and li ver aGVHD was observed in 40% and 66% of patients, respectively. Despite in itial improvement, 52 patients (90%) died a median of 40 days after ATG the rapy from progressive aGVHD and/or infection (74%), ARDS (15%), or relapse (11%). Only six patients (10%), three of whom had aGVHD limited to the skin at the time ATG was administered, are longterm survivors. We conclude that initial improvement of SR aGVHD occurs with ATG in a minority of patients, and very few patients become long-term survivors. Furthermore, this treatm ent is associated with a high rate of major complications.