Graft-versus-host-disease (GVHD) is a condition that can occur when you have an allogeneic transplant.

The immune system is the body’s defense against infections. White blood cells circulate through the bloodstream and body tissues. They destroy bacteria and other sources of infection. White blood cells called T lymphocytes, or T cells, are in charge of the immune system. These T cells distinguish cells belonging to your body from those that are foreign and should be attacked. When you have an allogeneic stem cell transplant, the donor cells may recognize your body’s cells as foreign. If so, the donor cells will tell the new immune system to attack your body's normal cells. This is called graft-versus-host disease, or GVHD.

The "graft" is the donor’s stem cells starting to grow in your body, and the "host" is you. Even if you are a complete match with your donor, you might still develop graft-versus-host disease. GVHD can range from a mild illness to a life-threatening complication. The disease can be acute, developing soon after the transplant, or chronic, lasting for many months after the transplant.

To prevent GVHD, we will give you medicines before and after transplant to suppress the immune cells in the graft. These are the cells that can cause GVHD. We will give you these medicines, called immunosuppressive drugs, at specific intervals. Another method of GVHD prevention is T-cell depletion of the graft. During this process, we remove some T lymphocytes from the stem cell graft before it is transplanted.

Development of GVHD can result in a lower risk of cancer relapse after BMT. In GVHD, the donor immune cells attack the body's normal tissues. They often attack the tumor cells as well. This is called graft-versus-tumor, GVT, or graft-versus-leukemia, (GVL).

If GVHD does occur, it can be stressful. Patients are usually expecting to get better just as GVHD emerges. Also, some of the symptoms of GVHD or side effects of its treatment can temporarily affect physical appearance. Some people feel self-conscious when faced with these symptoms.

Many people experience a wide range of feelings when complications such as GVHD occur. Patients may feel sad, worried, anxious, angry, or frightened. Some of these mood and emotional changes can also be caused by the steroid medicines (prednisone) used to treat GVHD.

Your health care team is available to support you as you cope with the difficult emotions and moods related to GVHD. Sometimes it is helpful to talk to others who have experienced GVHD. At times, antidepressant or anti-anxiety medications can help.

Understanding the symptoms of both acute and chronic GVHD can help you and your health care team detect it earlier. Prevention and early treatment of GVHD are keys to a successful allogeneic stem cell transplant.

Acute GVHD
Acute GVHD usually occurs during the first three months after the transplant—typically after your donor’s white cells start to grow (about three to six weeks). It can affect your skin, liver, and/or gut (gastrointestinal) tissues. GVHD can also increase your risk of serious infection.

On the skin, acute GVHD may appear as a raised red rash over your entire body, but it is often first seen on your face, ears, arms, and trunk. It can cover the palms of your hands or the soles of your feet. It can look like a sunburn and may peel and blister if it is severe.

The transplant team may recommend a skin biopsy to make sure the rash is GVHD and not a reaction to a medication. During a biopsy, we numb the skin, then remove a small piece of skin and examine it under the microscope. Once we diagnosis GVHD, we will start treatment with steroid creams and pills or IV medicines.

Liver GVHD causes jaundice (yellowing of the skin and of the white part of the eyes) and abnormal liver function tests. It’s usually diagnosed with blood tests, but occasionally a liver biopsy is needed.

The health care team will check your blood frequently for signs of liver GVHD.

Gut GVHD of the intestines causes watery diarrhea. GVHD of the stomach causes nausea, poor appetite, and vomiting. To diagnose gut GVHD, the transplant team will recommend a biopsy of your upper and/or lower digestive tract. Gastroenterologists perform this procedure. They are specialists in examining the stomach and intestines. Using a flexible, lighted telescope called an endoscope, they can examine and biopsy your stomach or intestines.

The treatment for acute GVHD consists of various medicines, including steroids. In addition, the health care team will treat your symptoms, which may include diarrhea, nausea, and vomiting. If you have severe forms of GVHD, we will want to treat you in the hospital. However, we can treat some milder forms of GVHD on an outpatient basis. Treatment of acute GVHD will take months. Eventually, when the graft accepts your body as home, you may be able to gradually stop taking your GVHD medicines.

Chronic GVHD
Chronic GVHD may develop three to six months after a transplant, sometimes even later. It may occur following acute GVHD or it may appear on its own. Chronic GVHD can affect the eyes, mouth, skin, stomach, or liver. You may develop chronic GVHD while at home recovering from the transplant, so it’s important to know the symptoms:

• Dry, scaly, or shiny skin
• Skin rash or discoloration
• Stiff joints or muscles
• Dryness or soreness in your mouth
• Lost of appetite, nausea or weight loss
• Diarrhea
• Difficulty swallowing liquids or solids
• Yellowing of the skin and eyes (jaundice)
• Dry or burning eyes
• Eyes that are sensitive to light
• Shortness of breath or cough
• Vaginal dryness
• Recurrent infections

The skin is the most common area affected by chronic GVHD. At first the skin is red, itchy, and dry. Eventually it becomes discolored, thickened, and tight. Some hair may fall out or turn gray.

Sun exposure can bring on chronic GVHD. You should not sunbathe or use tanning beds after having a transplant. You should wear a sunscreen of at least 30 SPF when you are outdoors.

Keeping your skin moist will help prevent it from becoming overly dry and flaky. Use a gentle, mild soap and a good moisturizing lotion every day. A health care provider will prescribe steroid creams to ease itching and burning and to treat GVHD of the skin.

Chronic GVHD can cause stiff joints. People with more severe forms of GVHD may get a referral for occupational or physical therapy to help with joint and muscle problems.

Liver abnormalities may also occur in people with chronic GVHD. Yellowing of the eyes (jaundice) and abnormal results of liver tests are usually the only signs. Occasionally we will do a liver biopsy to confirm the diagnosis and rule out other possible causes, such as hepatitis or infection.

Chronic GVHD also affects the mucous membranes—the glands in the body that produce moisture, saliva, and tears.

• Mouth. Symptoms include pain, dryness, and irritation while eating certain foods. Food might not taste right. Rough spots or ulcers may form in your mouth, on your tongue, and inside your cheeks. Keeping your mouth clean is crucial to decrease the risk of infection. Artificial saliva helps with the dryness.
• Eyes. Symptoms include grittiness, burning, and itching. You may not produce tears when you cry. Eyedrops are helpful for reducing dryness and relieving itching. It may help to use these often.
• Digestive tract (gut). Symptoms include poor appetite, nausea, difficulty swallowing, vomiting and weight loss.
• Lungs. Symptoms include shortness of breath, wheezing, pneumonia or chronic bronchitis.

Treatment for chronic GVHD uses drugs, such as steroids, to suppress your immune system and decrease T-cell activity. Chronic GVHD usually takes a long time to resolve, with treatment lasting months to years.

Nutritional support, good hydration, physical therapy, and prevention of infection are important for complete recovery from chronic GVHD.

People with chronic GVHD have a higher risk of infection. If you don’t have GVHD, your immune system will be back to its normal infection-fighting strength approximately one to two years after the transplant. With GVHD, your immune system recovery will be delayed until you have completed GVHD treatment and the GVHD is gone.

While you have chronic GVHD, we will give youantibiotics to prevent certain infections. Contact a member of your health care team if you are exposed to chickenpox or shingles. You should not have immunizations with any live virus vaccines until you are off all treatment for chronic GVHD.