What is Graft Versus Host Disease?

If you've had a bone marrow or stem cell transplant, you'll want to watch for signs of graft versus host disease (GVHD). It's a common complication -- as many as 4 out of 5 people who get a transplant get it in some form.

It happens when the cells that come from a donor mistakenly attack your own cells. Its effects can range from mild to life-threatening.

A mild case of GVHD can be a good sign. If the donor immune cells attack your healthy cells, they're also fighting any leftover cancer cells. Your doctor may decide it's best not to treat it.

Symptoms

GVHD can show up in several different parts of your body. Usually, it affects your skin, digestive system, or liver. It often starts as an itchy rash on your palms and the soles of your feet. You may also have nausea, vomiting, or diarrhea.

Some of these symptoms can be side effects of the transplant or of procedures or medications that go along with it. They can also mean you have an infection. Your doctor may take a sample of tissue, called a biopsy, from the affected part of your body to find out. A specialist will look for signs of GVHD in the sample under a microscope.

There are two main types, based on when symptoms show up. Acute GVHD usually happens within 100 days of the transplant. Chronic GVHD usually appears later. You're more likely to get the chronic form if you've had the acute form, and sometimes the two happen at the same time.

Beyond the timing, differences in symptoms help determine what kind you have. With acute GVHD, you may have:

• A rash on your palms and soles, ears, face, or shoulders. It can become widespread. Your skin may blister and peel.
• Watery diarrhea, abdominal cramps, nausea, vomiting, or lack of appetite.
• A buildup of waste products in your liver, which makes your skin and eyes look yellow.
• Low levels of red blood cells or platelets.
• Fever.

A rash and digestive problems are also symptoms of chronic GVHD. But it involves other parts of your body, too. You may have:

• Dry, irritated eyes and sensitivity to light
• Dryness in your mouth and esophagus, which can lead to sores
• Joint pain
• Thick, darkened skin, brittle nails, and hair loss
• Vaginal dryness and irritation
• Wheezing and persistent cough

GVHD is broken into different stages and grades based on how bad the symptoms are. These stages and grades help doctors decide how to treat it and can be a sign of how likely you are to recover.

Causes

During chemotherapy, cells inside your bone marrow that make blood are killed along with cancer cells. A transplant of someone else's bone marrow or stem cells lets your body make new blood cells.

But with GVHD, donor immune cells can attack your healthy cells as if they were bacteria or a virus.

You're most likely to get it if your proteins which protect your body's cells don't match your donor's very well. Other things that can increase your risk include:

• Your age (the older you are, the higher your chances of getting it)
• Donated material that contains a lot of the kind of white blood cells known as T cells
• Being a man and your donor is a woman who's had children
• Developing cytomegalovirus (a common virus that doesn't usually cause problems if you're healthy)

The more closely your cells match those of your donor, the better. Unless you have an identical twin, your best match will be a sibling or parent. But you may find a good match in a national registry. The risk also goes down if doctors get the donor cells from umbilical cord blood rather than peripheral blood or bone marrow.

Certain medications taken before and after the transplant can help prevent GVHD. You'll get a combination of drugs that slow down your immune system to keep the new white blood cells from going on the attack.

Treatment

If your GVHD is severe enough to need treatment, your doctor probably will prescribe a combination of corticosteroids, such as prednisone, and drugs that slow down your immune system, such as cyclosporine. Those can make it harder for your body to fight infections, so you may also get prophylactic antibiotics. If the problem persists, your doctor may prescribe a kinase inhibitor.

Other treatments can help you manage the symptoms in specific parts of your body.

• Skin: You may get a steroid cream for the itchy rash. Keep your skin moisturized, and protect yourself from the sun.
• Digestive system: You can get dehydrated fast with severe diarrhea. Avoid spicy or acidic foods. In extreme cases, you may be given water through an IV or be fed through a tube to keep your weight up. You'll have to limit fat and fiber until your intestines recover.
• Mouth: You may get special rinses to clean your mouth and keep it moist.
• Eyes: Artificial tears or steroid drops fight dryness and keep your eyes from being scratched.
• Immune system: Because you're at high risk for infection, stay away from crowds and sick people. Avoid exposure to fungus from gardening or animal waste. Never get a live vaccine.

GVHD usually goes away a year or so after the transplant, when your body starts to make its own white blood cells from the donor cells. But some people have to manage it for many years.

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