Key points of this article:
- If a patient receives a bone marrow or stem cell transplant, it is important to monitor for signs of graft versus host disease (GVHD). This is a common complication – up to 4 in 5 patients who receive a transplant may exhibit some form of graft versus host disease.
- Graft-versus-host disease is said to occur when cells from a donor donor mistakenly attack the patient’s own cells. It varies in severity and may be only mildly symptomatic or life-threatening.
- Mild graft-versus-host disease may be a good sign. If the donor’s immune cells will attack the patient’s healthy cells, they will also attack any residual tumor cells. Clinicians will determine on a case-by-case basis whether treatment for graft-versus-host disease is needed.
Symptoms
Graft-versus-host disease can appear in different parts of a patient’s body. Usually, it spreads to the patient’s skin, digestive system, or liver. It starts with an itchy rash on the palms of the hands and soles of the feet, and may be accompanied by nausea, vomiting, or diarrhea.
Some symptoms may also be a side effect of the transplant treatment, or the manipulation or medication associated with it; they may also be a clinical manifestation of the patient’s infection. The physician will need to take a tissue sample from the patient’s lesion, called a tissue biopsy. The tissue sample is then looked at under a microscope for signs of graft-versus-host disease.
Graft-versus-host disease can be divided into 2 main types based on when symptoms appear:
- Acute graft-versus-host disease usually occurs within 100 days of transplantation;
- Chronic graft-versus-host disease appears later.
- Chronic graft-versus-host disease occurs later.
If a patient has acute symptoms, he or she is more likely to have chronic symptoms in a subsequent phase, and sometimes the 2 types of symptoms can occur together.
In addition to the timing of onset, differences in the patient’s symptoms can help determine which type of graft-versus-host disease is present. If a patient has acute graft-versus-host disease, symptoms may include:
- A rash on the palms of the hands, feet, ears, face, or shoulders. The spread is so extensive that the patient’s skin blisters and flakes.
- Aqueous diarrhea, abdominal cramps, nausea, vomiting, or loss of appetite.
- Metabolic waste accumulates in the liver to form jaundice, leaving the patient’s skin and eyes tinged with yellow.
- Red blood cell or platelet levels are reduced.
- Fever.
Symptoms of chronic graft-versus-host disease also include rash and digestive abnormalities. In addition, it may involve other parts of the patient’s body and may include:
- Dry, sore eyes with sensitivity to light;
- Dryness of the mouth and esophagus, with resulting ulcers;
- Joint pain;
- Thickening and dulling of the skin, brittle nails, and easy hair loss;
- Vaginal dryness and pain in female patients;
- Shortness of breath and persistent cough.
Graft-versus-host disease can be staged and graded according to the severity of symptoms. These staging and grading can help doctors make decisions about how to treat and assess the patient’s eventual recovery.
Etiology
During chemotherapy, hematopoietic stem cells and tumor cells in the bone marrow are killed at the same time. Receiving a bone marrow or stem cell transplant from a donor allows the patient’s body to start producing new blood cells again.
But during an attack of graft-versus-host disease, the leukocytes produced by the donor stem cells to fight the disease attack because they do not recognize the patient’s own healthy cells as pathogens similar to exogenous bacteria or viruses.
Some degree of graft-versus-host disease may occur if the patient’s genotype does not match the donor’s stem cell genotype exactly. Other factors that can increase the risk of developing the disease include:
- Patient age: the older the patient, the higher the risk of developing the disease;
- Bone marrow or blood samples from the donor contain high levels of T cells;
- The patient is male and the donor of the stem cells is a female who has given birth before;
- The patient is male and the donor of the stem cells is a female who has given birth before;
- The donor of the donated stem cells carries cytomegalovirus (a common virus that usually does not cause serious health problems if you are healthy).
The better the match between the donor cells and the patient’s cells, the better. Other than identical twins, the best matches are siblings or parents. If a family member fails to match, the patient can also search the national stem cell donor database for a genetically matched volunteer. The risk of graft-versus-host disease is also reduced if the patient transplants donor cells obtained from umbilical cord blood.
Pharmacological control before and after transplantation can help prevent graft-versus-host disease. Through a combination drug regimen, the patient’s immune system is suppressed and newly generated leukocytes are prevented from attacking the patient’s own cells.
Treatment
If a patient’s graft-versus-host disease is severe enough to require treatment, then doctors usually use a combination regimen that includes a glucocorticoid, such as prednisone, and an immune system suppressant, such as cyclosporine. The use of these drugs further increases the risk of infection, so patients also need to take antibiotics prophylactically.
Other treatments can help patients manage symptoms in specific areas of the body.
- Skin: Patients can treat pruritic rashes with glucocorticoid ointments. Take care to keep the skin moist and away from the sun during the day.
- Digestive system: In case of severe diarrhea, patients can become dehydrated quickly. Daily care should be taken to avoid spicy or acidic foods. In extremely severe cases, patients need to be rehydrated intravenously or have food delivered through a gastric feeding tube to maintain weight. Patients must limit fat and fiber intake until the bowel returns to normal.
- Mouth: Patients can use a special mouthwash to clean the mouth and keep it moist.
- Eyes: Use artificial tears or glucocorticoid drops to combat eye dryness and prevent eye damage.
- Immune system: Because of the high risk of infection associated with the patient, it is necessary to stay away from people, especially from people with other infectious diseases. Avoid contact with fungi or animal feces in landscaping, and never get live attenuated vaccines.
Graft-versus-host disease usually resolves about a year after transplantation, when the patient’s body has begun to produce its own white blood cells from donor cells. However, there are some patients who require years of disease management for this disease.