Graft vs Host Disease: An Overview in Bone Marrow Transplant
What is graft versus host disease?
Graft versus host disease (GvHD) is a condition that might occur after an allogeneic transplant. In GvHD, the donated bone marrow or peripheral blood stem cells view the recipient’s body as foreign, and the donated cells/bone marrow attack the body.
There are two forms of GvHD:
Acute graft versus host disease (aGvHD).
Chronic graft versus host disease (cGvHD).
As an allogeneic transplant recipient, you might experience either form of GvHD, both forms, or neither.
Acute graft versus host disease
Several factors are thought to increase the development of acute GvHD. The most important factor is donor/recipient HLA (human leukocyte antigen) match, in which there are differences between you and your donor. The differences can cause donor cells to recognize your cells as foreign, and lead to an immune response against your tissues and organs.
Recipients who have received peripheral blood stem cells/bone marrow from an HLA mismatched related donor ( or from an HLA matched unrelated donor) have an increased risk of developing acute GvHD.
Other donor/ recipient factors that might increase the risk of developing aGvHD include:
A female donor who has been pregnant in the past
The advanced age of either the donor or the recipient
When/where it might occur
Acute GvHD might occur once the donor's cells have engrafted in the transplant recipient. It might develop in your skin, liver, eyes, or gastrointestinal tract, and symptoms might appear within weeks after your transplant.
Your BMT doctor can make the diagnosis of a GvHD during a physical exam by observing certain symptoms and/or by evaluating the results of site biopsies and lab values.
Symptoms to report
Because of the increased risk of developing infections, it is very important to report any fevers of 100.4° F or higher to your BMT Coordinator during business hours. After hours, call Clinic Operator at 216.444.2200, ask to speak to the Hematology Fellow on call, who can triage symptoms and determine urgency.
Please report any physical changes you might experience to your BMT Team. Symptoms of acute GvHD might include any of the following:
Skin rash or reddened areas on the skin (signs of aGvHD of the skin) — Please report if your skin is itchy.
Yellow discoloration of the skin and/or eyes, and abnormal blood test results (signs of
aGvHD of the liver)
Nausea, vomiting, diarrhea, or abdominal cramping (signs of aGvHD in the gastrointestinal tract, or “gut”)
Increased dryness/irritation of the eyes (signs of GvHD of the eyes)
If aGvHD occurs, your doctor will discuss available treatment options with you and your family. Many patients are successfully treated with increased immunosuppression in the form of oral or intravenous steroid medicines.
Chronic Graft versus Host Disease
Some doctors believe that cGvHD is a later phase of aGvHD, while others believe it is
a separate condition that is similar to an autoimmune process.
Patients who have an increased risk of developing cGvHD are those who have received stem cells/bone marrow from an HLA (human leukocyte antigen) mismatched related donor
or from an HLA matched unrelated donor, patients that may have already experienced
acute GvHD, and older recipients.
When/where it might occur
Chronic GvHD can appear at any time after allogenic transplant or several years after your transplant. Chronic GvHD might occur in the skin, liver, eyes, mouth, lungs, gastrointestinal tract, neuromuscular system, or genitourinary tract.
Your BMT doctor might be able to make the diagnosis of cGvHD during a physical exam by observing certain symptoms and/or by evaluating the results of site biopsies and lab values.
Some symptoms of cGvHD might be very vague, which might make the diagnosis possible only after other causes are excluded.
Symptoms to report
Because of the increased risk of developing infections, it is very important to report any fevers of 100.4° F or higher to your BMT Coordinator during business hours. After hours, contact the Oncology fellow on-call.
Please report any physical changes you might experience to your BMT Team. Symptoms of chronic GvHD might include any of the following:
Rash, raised, or discolored areas, skin thickening or tightening (signs of cGvHD of the skin)
Abdominal swelling, yellow discoloration of the skin and/or eyes, and abnormal blood test results (signs of cGvHD of the liver)
Dry eyes or vision changes (signs of cGvHD of the eyes)
Dry mouth, white patches inside the mouth, pain or sensitivity to spicy foods (signs of oral cGvHD, of the mouth)
Shortness of breath or changes seen on your chest X-ray (signs of dry cough pulmonary cGvHD — of the lungs)
Difficulty swallowing, pain with swallowing, or weight loss (signs of cGvHD of the gastrointestinal tract or “gut”)
Fatigue, muscle weakness, or pain (signs of neuromuscular cGvHD, of the nerves and muscles)
Increased need to urinate (urinary frequency), burning or bleeding with urination, vaginal dryness/ tightening, or penile dysfunction (signs of cGvHD of the genitourinary system, bladder, or sexual organs)
If cGvHD occurs, your doctor will discuss available treatment options with you and your family. Long-term immunosuppressive medicines are usually the treatment regimen for cGvHD. Fungal, bacterial, and viral infections are a major risk with this treatment option since your immune system will be suppressed for a very long time. Your doctor will prescribe several medicines to help prevent these life-threatening infections from occurring.
Tissue typing labs have been developing and using more precise DNA level tests
to enable your BMT Team to select the best HLA matched donor for you.
We try to lower your risk of developing GvHD by giving you preventive (prophylactic) immunosuppressive medicines after your transplant. These medicines will decrease the ability of
your donor's T cells to start an immune response against your own tissues.
Fungal, bacterial, and viral infections are major risks with this prophylactic medicine regimen, since your immune system will be suppressed and have a decreased ability to fight infection.
New, and hopefully better, methods to prevent GvHD are being studied in clinical trials. The use of photopheresis, different immunosuppressive drugs, and new monoclonal antibodies given to recipients after transplant, as well as methods to remove donor T cells prior to transplant, are examples of some of that research.
While GvHD can deeply impact your quality of life, it does have some benefit. The same immune response responsible for attacking your normal cells is also monitoring and destroying any surviving cancer cells. This is called the graft versus tumor effect. Patients who develop GvHD have lower disease relapse rates.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 2/27/2014...#10255