Glucksberg and IBMTR Acute GVHD Grading

Organ staging and overall grading of acute graft versus host disease

1. Determine aGVHD stage for each target organ (skin, liver and gut)

Skin stageBody surface area involved by maculopapular rash
1< 25%
225 - 50%
3> 50% or generalised erythroderma
4Generalised erythroderma with bullous formation or desquamation

Liver stageBilirubin in μmol/L *Bilirubin in mg/dL *
134 – 50 (or AST 150-750 U/L)2 - 3 (or AST 150-750 U/L)
251 – 102> 3 – 6
3103 – 255> 6 – 15
4> 255> 15
* Downgrade by one stage if additional cause of hyperbilirubinemia documented
Gut stageDaily stool volume
1> 30 mL/kg or > 500mL*
2> 60 mL/kg or > 1000mL
3> 90 mL/kg or > 1500 mL
4> 2000 mL/day or severe abdominal pain +/- ileus
* Persistent nausea with histologic evidence of stomach or duodenal aGVHD counts as stage 1 gut

2. Determine overall aGVHD grade using the Glucksberg or IBMTR system

Overall grade (Glucksberg)Criteria1 year mortality (odds ratio compared to no GVHD)4
ISkin stage 1 or 2 only (no liver or gut aGVHD)0.8
IIUp to stage 1 liver or gut, up to stage 3 skin0.8
IIIUp to stage 4 liver, up to stage 3 in any other organ2.2
IVStage 4 skin or gut, ECOG/WHO performance status 4 or Karnofsky performance score < 30%13.1
Overall grade (IBMTR)Criteria1 year mortality (odds ratio compared to no GVHD)4
AStage 1 skin only0.8
BMaximum stage 2 in any organ0.8
CMaximum stage 3 in any organ1.4
DStage 4 in any organ12.3

Consensus guidelines on grading of acute graft versus host disease (aGVHD) were published in 1995.1 Stage of aGVHD is determined separately in the three main target organs (skin, liver and gut); these grades are then used to determine an overall aGVHD grade, using either the International Bone Marrow Transplant Registry (IBMTR)2 or Glucksberg3 criteria.

The IBMTR and Glucksberg criteria were prospectively validated in 607 patients receiving myeloablative T cell-replete allogeneic stem cell transplants between 1996 and 1999.4 Both systems were predictive of mortality at 100 days and one year post-transplant.