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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 bone marrow transplant. In GvHD, the donated bone marrow or 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. The
most important factor is donor/recipient HLA match, in which there are
differences between you and your stem cell/bone marrow 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 stem cells/bone marrow from an HLA
(human leukocyte antigen) 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:
- Differences between the sex of the donor and the recipient
- 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 bone marrow/stem cells have
engrafted in the transplant recipient. It might develop in your skin, liver, or
gastrointestinal tract, and symptoms might appear within weeks after your
transplant.
Diagnosis
Your BMT doctor can make the diagnosis of aGvHD 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 degrees 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 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)
Treatment
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
Risk factors
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, those
who have already experienced acute GvHD, and older recipients.
When/where it might occur
Chronic GvHD can appear at any time after bone marrow 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.
Diagnosis
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 degrees 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, 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
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 or tightening, or penile dysfunction
(signs of cGvHD of the genitourinary system, bladder, or sexual organs).
Treatment
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
Tissue typing labs have been developing and using more precise DNA level
tests to enable your Bone Marrow Transplant 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 and intravenous
immunoglobulins after your bone marrow 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.
Important note
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 for and destroying any surviving cancer cells. This is called
the graft versus tumor effect. Patients who develop GvHD have lower disease
relapse rates.
©
Copyright 1995-2009 The Cleveland Clinic Foundation. All rights reserved.
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