GvHD explained
GvHD is a common complication of an allogeneic stem cell transplant. This is a type of transplant where you receive stem cells from a donor, usually a blood relative. The donor stem cells are used to replace the diseased blood cells and repair your bone marrow.
GvHD happens when donated stem cells (the graft) mature into immune cells. They attack healthy cells in your body (the host).
Symptoms can be mild rashes to serious life-threatening damage to your skin and organs. But most cases of GvHD are mild to moderate, which can be managed with minor treatment.
People at risk of GvHD
It is difficult to predict who will be affected by acute or chronic GvHD. Common risk factors include:
- degree of human leukocyte antigen mismatch
- donor and recipient gender difference
- intensity of pre transplant conditioning (treatment) regimen
- whether you received total body irradiation (TBI)
- the source of the donor stem cells (peripheral blood, bone marrow or cord blood)
- type of blood cancer being treated
- age of donor and patient
- previous acute GvHD.
GvHD classification
Acute GvHD (aGvHD)
- usually occurs within the first 100 days of receiving a stem cell transplant
- can affect the skin, liver, and gastrointestinal tract
- affects 20 – 50% of allogeneic stem cell transplant recipients
- is classified using a standardised staging and grading system
Chronic GvHD (cGvHD)
- can occur at any time but normally develops 100 days or more after transplant
- may involve one or multiple organs
- affects approximately 40% of transplant recipients
- is classified as mild, moderate, or severe using the NIH global severity of cGvHD scale.
Signs and symptoms of GvHD
- Rash.
- Dry, tight, itchy skin.
- Thickening of the skin.
- Change in skin colour.
- Skin sores that don’t heal.
- Unable to tolerate temperature changes.
Management
- Sometimes a skin biopsy is done to confirm a diagnosis of GvHD of the skin.
- Mild cases may be treated with moisturises and special creams.
- Medication can be given to suppress your new immune system in more severe cases.
- Treatment such as extracorporeal photopheresis (ECP) is a possible option.
- You may be referred to a dermatologist.
- Dry, painful, itchy eyes.
- Unable to tolerate bright lights.
- Blurred vision.
- Blindness.
Management
- Eye drops may be used.
- Wearing sunglasses may help
- A referral to an eye specialist (ophthalmologist) may be needed.
- Change to nail texture.
- Hard brittle nails.
- Nail loss.
Management
- Use dish gloves when using household cleaning chemicals.
- Use lukewarm water to wash your hands.
- Apply a nail hardener to protect the nail.
- Dry mouth.
- Cold and hot sensitivity.
- Mouth ulcers.
- Trouble eating.
- Gum disease and tooth decay.
- Trouble swallowing.
Management
- Practice good oral hygiene including regular mouthwashes.
- You may be prescribed steroid creams, ointments, and mouthwashes.
- Have regular dental checks.
- Hair loss on your head.
- Early onset of grey hairs.
- Loss of body hair.
Management
- Wash your hair less frequently to avoid drying it out.
- Use a neutral or gentle shampoo, such as baby shampoo.
- Wear a hat to protect your scalp from the sun.
- Keep skin moisturised with fragrance-free creams.
- Loss of appetite.
- Unexpected weight loss.
- Nausea.
- Vomiting.
- Diarrhoea.
- Stomach pain.
Management
- You may be given medications for diarrhoea.
- Sometimes intravenous fluids are given to replace fluids that are lost from the diarrhoea and to prevent dehydration.
- Your gut may need a rest from processing food and complex fluids. Support with nutrition is sometimes given through a drip into your central line. This is called total parenteral nutrition (TPN).
- Muscle weakness and cramping.
- Joint stiffness, tightness and difficulty extending limbs.
Management
- Ask for a referral for exercise rehabilitation.
- Exercise, including stretching, can help improve symptoms.
- Massage will help with flexibility.
- Breathlessness.
- Cough that doesn’t go away.
- Wheezing.
Management
- You could have tests such as x-rays, CT scans and Bronchoscopies (a type of procedure that looks inside your airways) to find out what is causing the problem.
- You may be prescribed steroids, oral and inhalers/puffers, which may be given with antibiotics to prevent infections.
- You may need oxygen therapy.
- Yellowing of the skin or the whites of the eyes.
- Pain or swelling in the upper right of the abdomen.
Management
- You may be prescribed steroids and other medications to suppress your immune system.
- Vaginal/penile dryness, itching and pain.
- Vaginal ulcerations and scarring.
- Difficult or painful intercourse.
Management
- You may be prescribed steroid creams or gel to help with dryness and reduce sensitivity.
- Women will be referred to a Gynaecologist.
- Men will be referred to a Urologist.
If you have symptoms of GvHD, you should talk to your treatment team. Ask for a referral to someone who specialises in the area you are having symptoms.
Preventing GvHD
There are actions your treatment team may take to reduce your risk of getting GvHD. These include:
- making sure your donor is as close a match as possible
- pre and post-transplant immunosuppressive treatment.
Treatment for GvHD
Treatment for GvHD depends on the type you have, which parts of your body are affected, how severe your symptoms are, and any treatments you’ve already received. Treatment aims to manage your symptoms and the GvHD.
Commonly used treatments
Steroids
This is the most common treatment for GvHD. Steroids suppress your new immune system and reduce inflammation.
Steroid can be taken as:
- a tablet
- an injection into a vein
- a cream, which is commonly used for skin GvHD
- eye drops, which can be used for eye GvHD.
Immunosuppressants
This treatment is used to calm down your new immune system, so it doesn’t attack your own body. These medications can also be given to reduce your risk of getting GvHD in the first place.
Examples include:
- calcineurin inhibitors such as tacrolimus and cyclosporin
- mycophenolate.
Extracorporeal photopheresis (ECP)
ECP is also known as light therapy. It can be used to treat GvHD when other treatments haven’t worked. The aim of ECP is to slow or stop your new immune system from attacking your healthy cells. It is a complicated process and can take up to six months before you see an improvement in your symptoms.
The process of ECP involves three main steps:
- Collect your white blood cells through a process called leukapheresis.
- Treat the collected white blood cells with medication and UV light.
- Reinfuse the white blood cells back into you.
You will have a needle inserted into a vein for this procedure or you may need a central venous access device (CVAD).
Clinical trials for GvHD
There are Clinical trials that test new drugs and therapies on how to prevent and treat GvHD. Your treatment team can help determine which clinical trials may be an option for you. Learn more about clinical trials.
References
- Graft-versus-host disease (GVHD) | Blood Cancer United
- National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: IIa. The 2020 Clinical Implementation and Early Diagnosis Working Group Report – PMC
- Preventing GVHD after a Stem Cell Transplant – NCI
- 3829-Chronic graft versus host disease (cGVHD) | eviQ
- 3815-Acute graft versus host disease (aGVHD) | eviQ
- Photopheresis: Treatment Uses and Side Effects
