Graft vs. Host Disease

What is graft vs. host disease (GvHD)?

Graft versus host disease (GvHD) is a complication that might occur after an allogeneic transplant. During an allogeneic transplant, your healthcare provider transplants hematopoietic stem cells (immature blood cells) from a donor into your body. The donated stem cells eventually become mature blood cells.

You may need donor stem cells if you have an issue with your blood cells, as with cancers like leukemia or lymphoma, or other bone marrow failure diseases like aplastic anemia.

In GvHD, the donated stem cells (graft) view the recipient’s cells (host) as an unfamiliar threat. As a result, the donated cells attack the recipient’s cells. This is why the disease is called “graft” versus “host.”

What are the types of GvHD?

There are two main types of GvHD. Previously, healthcare providers classified GvHD based on when symptoms started. More recently, providers diagnose the specific type of GvHD based on symptoms and clinical signs (like the results of tests or imaging) in addition to the timing of symptom onset.

• Acute graft versus host disease (aGvHD): aGvHD occurs shortly after your transplant, usually within the first 100 days. But symptoms of aGvHD may also start later. aGvHD most often affects your skin, gastrointestinal (GI) tract or liver.
• Chronic graft versus host disease (cGvHD): cGvHD can appear any time after an allogenic transplant, but most cases start within two years. Chronic GvHD might affect your skin, mouth, liver, lungs, GI tract, muscles, joints or genitals.

As an allogeneic transplant recipient, you might experience either form of GvHD, both forms or neither.

What are the symptoms of GvHD?

Symptoms of GvHD range from mild to moderate to severe (potentially fatal).

Acute GvHD

Symptoms of aGvHD most often affect your skin, gastrointestinal (GI) tract or liver.

The most common symptom of skin aGvHD is a rash or reddened areas on your skin (similar to a sunburn). The skin may feel painful or itchy. These rashes usually start on your neck, shoulders, ears and the palms of your hands and soles of your feet. The rash can spread to other parts of your body.

The most common symptoms of GI aGvHD are nausea, vomiting and diarrhea. Symptoms can be mild or severe enough that you may need to visit the hospital for treatment.

Symptoms may include:

• Rash and/or itching.
• Diarrhea.
• Nausea and vomiting.
• Abdominal cramping.
• Jaundice (yellow discoloration of your skin and/or eyes).

Chronic GvHD

cGvHD most commonly affects your skin, liver, GI tract and lungs, but it can affect any body part. Symptoms may include:

• Rash and/or itching.
• Skin tightness and swelling.
• Hair loss on your head and body.
• Dry mouth.
• Mouth sores.
• Gum disease.
• Dry or gritty feeling in your eyes.
• Vision changes.
• Diarrhea.
• Nausea and vomiting.
• Yellow discoloration of your skin and/or eyes (jaundice).
• Shortness of breath (dyspnea).
• Dry, persistent cough.
• Fatigue.
• Muscle weakness, cramping or pain.
• Decreased range of motion in joints.
• Vaginal dryness, itchiness or pain with intercourse.
• Itchy penis or scrotum or pain with intercourse.

What causes GvHD?

With GvHD, donor stem cells from an allogeneic stem cell transplant attack because they see your body’s cells as a threat.

Normally, blood cells in your immune system keep you free of infection by fighting invaders that don’t belong, like viruses and bacteria. These blood cells don’t attack your body’s cells because they recognize a protein on them called human leukocyte antigens (HLA). Think of HLA as a nametag that identifies a cell as belonging in your body.

Except for identical twins, everyone has different HLAs.

After an allogeneic transplant, your body makes new blood cells from donated stem cells. These new blood cells will have HLA like your donor’s — not yours. If the HLA is too different from yours, the donated blood cells will attack your body’s cells.

Healthcare providers who perform these transplants test a potential donor’s HLA carefully to find a close match to yours to reduce the risk of GvHD. But unless you’re receiving donated cells from an identical twin, there’s a chance of developing GvHD.

Who is at the greatest risk for GvHD?

The most important risk factor is donor/recipient HLA match. You’re at an increased risk of developing GvHD if you’ve:

• Received stem cells from an HLA-mismatched donor who is related to you.
• Received stem cells from an HLA-matched donor who is not related to you.

Other risk factors include:

• A donor who’s been pregnant in the past.
• The advanced age of either the donor or the recipient.
• Mismatched sex between donor/recipient (male donor/female recipient or vice versa).
• Donor stem cells taken from the bloodstream instead of the bone marrow (where blood cells are made).

You may be at greater risk of developing chronic GvHD if you’ve already experienced acute GvHD.

How is graft versus host disease diagnosed?

Your healthcare provider can diagnose GvHD during a physical exam by observing certain symptoms and evaluating lab tests and biopsy results. During a biopsy, a provider removes a sample of tissue or cells and sends the sample to a lab for testing.

In the case of chronic graft versus host disease (cGvHD), some symptoms may indicate multiple potential conditions. Your provider will make a diagnosis after eliminating other causes.

What is the treatment for GvHD?

You’ll receive preventive (prophylactic) medicines to suppress your immune system after your transplant. These immunosuppressive medicines decrease donor cells’ ability to start an immune response (attack) against your tissues.

If these medicines don’t prevent you from developing GvHD, your provider will prescribe treatments based on the severity of your condition and the type of GvHD.

Treating acute GvHD

Healthcare providers successfully treat many people with aGvHD by increasing immunosuppressive medicines in the form of oral (given by mouth), intravenous (given through a vein) or topical (applied to your skin) corticosteroids. If steroids don’t help, your provider may prescribe Ruxolitinib (Jakafi®). You may also be eligible for clinical trials. A clinical trial is a study to test the safety and effectiveness of new treatments and new combinations of current treatments.

Treating chronic GvHD

Providers usually prescribe long-term immunosuppressive medicines to treat cGvHD. If these medicines don’t improve your condition, your provider may prescribe:

• Ruxolitinib (Jakafi®).
• Belumosudil (Rezurock™).
• Ibrutinib (Imbruvica®).
• Photopheresis.

You may be eligible for clinical trials, which your provider will discuss with you.

Complications/side effects of the treatment

Immunosuppressive medicines weaken your immune system, putting you at risk for fungal, bacterial and viral infections. Your healthcare provider will prescribe several medicines to help prevent potentially life-threatening infections from occurring.

How can GvHD be prevented?

Tissue typing labs are continually developing and using more precise DNA level tests to enable your care team to select the best HLA-matched donor for you. Closer matches can help prevent GvHD.

Your healthcare provider will prescribe immunosuppressants after your transplant to prevent GvHD.

Can GvHD be cured?

Healthcare providers can often manage GvHD successfully.

In the meantime, researchers are studying new methods to prevent GvHD in clinical trials. Examples of this research include different immunosuppressive drugs and new prophylaxis medications.

Is GvHD life-threatening?

GvHD can be life-threatening. Chronic GvHD is the most common cause of death in people receiving an allogeneic stem cell transplant, other than the disease itself.

It’s important to discuss the risk factors of any treatment — including a stem cell transplant — with your healthcare provider before treatment. They can explain potential risks to you and help you weigh the pros and cons of treatment.

What are the potential benefits of GvHD?

While GvHD can negatively impact your quality of life, it does have some benefits. The same immune response responsible for attacking your normal cells also monitors and destroys any surviving cancer cells. This is called the graft-versus-tumor effect. People who develop GvHD have lower disease relapse rates.

How do I take care of myself?

Your healthcare provider will explain how to care for yourself after your transplant. For example, they’ll describe what symptoms to watch out for. They’ll explain which symptoms require you to contact your care team immediately. They may also provide tips to care for yourself if you’re at risk of developing GvHD. These tips may include:

• Protect your skin from sun exposure by wearing long-sleeved shirts and long pants and using sunscreen with a minimum SPF of 50. (Sun exposure can trigger or worsen GvHD.)
• Practice good dental hygiene to reduce your susceptibility to gum disease.
• Avoid foods that can upset your stomach or irritate your mouth, like spicy foods.
• Take steps to prevent exposing yourself to germs.

When should I see my healthcare provider?

It’s essential that you report any physical changes, especially symptoms of infection and fevers of 100.4 degrees Fahrenheit F (38 degrees Celsius) or higher to your healthcare provider. You’re at increased risk of developing potentially life-threatening infections when taking immunosuppressants.

A note from Cleveland Clinic

Your healthcare provider will monitor your health after an allogeneic stem cell transplant for signs of complications like graft versus host disease (GvHD). If you show signs of acute or chronic GvHD, your provider may adjust your medications or they may prescribe new medicines. Be sure to take all medicines as prescribed. Follow your provider’s guidance on taking steps to care for yourself, including ways to reduce your risk of infection.