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Graft vs Host Disease: An Overview in Bone Marrow Transplant


Overview | Diagnosis and Tests | Management and Treatment | Prevention

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

Risk factors

Several factors are thought to increase the development of acute GvHD (aGvHD). 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 acute graft versus host disease 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.

Chronic graft versus host disease

Risk factors for 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 chronic graft versus host disease 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.

Important note about graft versus host disease: 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.

What are symptoms of acute graft versus host disease (aGvHD)?

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)

What are symptoms of chronic graft versus host disease (cGvHD)?

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)

Diagnosis and Tests

How is graft versus host disease diagnosed?

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.

In the case of chronic graft versus host disease (cGvHD), some symptoms might be very vague, which might make the diagnosis possible only after other causes are excluded.

Management and Treatment

How is acute graft versus host disease treated?

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.

How is chronic graft versus host disease treated?

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.

Prevention

How can graft versus host disease prevented?

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.

Research

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.

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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 healthcare provider. Please consult your healthcare provider for advice about a specific medical condition. This document was last reviewed on: 02/27/2014