Childhood leukemia

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Graft-versus-host disease (GVHD)

Graft-versus-host disease (GVHD) occurs when the healthy stem cells from the donor (called the graft) have an immune response to the recipient’s cells (called the host). The graft cells see the host cells as foreign and start to destroy them. Donor T cells attack the recipient’s organs and tissues.

The chance of developing GVHD is higher in older adults and in people who receive stem cells from an unrelated or mismatched donor. Some allogeneic transplant recipients may never develop GVDS. Others develop acute GVHD, chronic GVDH or both.

Acute GVHD

Acute GVHD starts within the first 100 days of the transplant. It can be mild to very severe. Acute GVHD occurs in about one-third to one-half of allogeneic transplant recipients. It can cause different problems, depending on the organs affected.

Skin problems include:

  • burning and redness of skin on the palms of the hands or soles of the feet
  • rashes that can spread to the chest and entire body
  • blisters
  • flaking skin

Digestive problems that can occur if the intestines, or bowels, are affected include:

  • nausea and vomiting
  • severe diarrhea
  • cramping or abdominal pain

If the liver is affected, it can cause:

  • liver tenderness
  • enlarged liver
  • abnormal liver enzymes
  • jaundice, which is a condition that makes the eyes or skin yellow
  • liver failure

Doctors may grade, or measure, how severe acute GVHD is. This helps them develop a treatment plan.

Grades of acute GVHD

1 (mild)

skin rash covering less than 25% of the body

2 (moderate)

skin rash covering more than 25% of the body

mild liver and intestinal problems

3 (severe)

generalized skin redness

moderate liver and intestinal problems

4 (life-threatening)

blisters and peeling skin

severe liver and intestinal problems

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Chronic GVHD

Chronic GVHD is more likely to occur in recipients who have acute GVHD. It usually occurs between 100 days to a year after a stem cell transplant, but it can develop more than a year after the stem cell transplant. Chronic GVHD occurs in up to 60% of allogeneic transplants.

Chronic GVHD can affect almost any part of the body. It can cause different problems, depending on the organs affected. In some cases, chronic GVHD can permanently damage an organ, so these symptoms continue even after GVHD is resolved.

Skin problems include:

  • rash and itching, which are the earliest signs
  • peeling, like a sunburn
  • darkening of skin colour
  • hard texture
  • tight feeling
  • skin sensitivity, which can become a long-term problem

Chronic GVHD can cause dry eye syndrome, which includes dry, burning eyes.

Mouth problems include:

  • dry mouth
  • mouth sores
  • dental cavities and gum disease

Digestive problems that can occur if the intestines, or bowels, are affected include:

  • less appetite
  • diarrhea
  • abdominal cramps
  • weight loss

If the liver is affected, it can cause:

  • jaundice, which is a condition that makes the eyes or skin yellow
  • enlarged liver
  • pain in the abdomen
  • abnormal liver enzymes

Lung problems can include difficulty breathing and lung infection (called pneumonia).

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Preventing and managing GVHD

To help prevent GVHD, some of the immune cells that cause GVHD may be removed before the stem cell transplant (called T-cell depletion). Drugs are commonly given to prevent GVHD in allogeneic transplants when the donor is not an identical twin.

Drugs that suppress the immune system are used to prevent and treat GVHD. The recipient may take one or a combination of immune-suppressing drugs depending on the severity of GVHD. The recipient may have to take immune-suppressing drugs for months or years after an allogeneic transplant. These drugs include:

  • methotrexate
  • cyclosporine (Neoral)
  • corticosteroids, such as prednisone or methylprednisone (Medrol)
  • tacrolimus

The healthcare team will assess recipients for early signs of GVHD. Tell your healthcare team if you have any symptoms of GVHD. Antibiotics may be given to reduce the risk of infection while chronic GVHD is treated. Eye drops, such as artificial tears, can be used for dry eyes.

Recipients should protect themselves from too much exposure to the sun and should avoid sunburns.

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