Graft-versus-Host Disease (GVHD)
The immune system is the body's defense against infections. White blood cells circulate through the bloodstream and body tissues, destroying 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 child's body from those that are foreign and should be attacked. When your child has an allogeneic stem cell transplant, the donor cells may recognize your child's body's cells as foreign and tell the new immune system to attack your child'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 child's body, and the "host" is your child. Even if they're a complete match with their donor, they 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, your child will be given medications (immunosuppressive drugs) before and after transplant to suppress the immune cells in the graft, which can cause GVHD.
Another method of GVHD prevention is T-cell depletion of the graft, where some T lymphocytes are removed from the stem cell graft before it is transplanted.
Development of GVHD can result in a lower risk of cancer relapse after BMT. The immune attack on normal tissues as a result of GVHD often includes attack on the tumor cells (called graft-versustumor, GVT, or graft-versus-leukemia, GVL).
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 medications used to treat GVHD.
Your child's healthcare team is available to support them as your child copes 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 antianxiety medications can help.
Prevention and early treatment of GVHD are key to a successful allogeneic stem cell transplant.
Acute GVHD usually happens during the first three months after the transplant--typically after your child's donor's white cells start to grow (about three to six weeks). It can affect your child's skin, liver, and/or gut (gastrointestinal) tissues. GVHD can also increase your child's risk of serious infection.
On the skin, acute GVHD may appear as a raised red rash over your child's entire body, but it is often first seen on your child's face, ears, arms, and trunk. It can cover the palms of your child's hands or the soles of their 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. Once GVHD has been diagnosed, treatment with steroid creams and pills or IV medications will be started.
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.
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 child's upper and/or lower digestive tract. Children usually have heavier sedation or general anesthesia during this procedure.
Acute GVHD is treated with various medications, including steroids. In addition, the healthcare team will treat your child's symptoms, which may include diarrhea, nausea, and vomiting. Severe forms of GVHD are treated in the hospital, but some milder forms can be treated on an outpatient basis. Treatment of acute GVHD will take months. Eventually, when the graft accepts your child's body as home, they may be able to gradually stop taking their GVHD medications.
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. Your child 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 child's mouth
- Lost appetite, nausea, or weight loss
- 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. Your child should not sunbathe or use tanning beds after having a transplant. They should wear a sunscreen of at least 30 SPF when they're outdoors.
Keeping your child's 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 healthcare provider will prescribe steroid creams to ease itching and burning and to treat GVHD of the skin.
As chronic GVHD can cause stiff joints, people with more severe forms of GVHD may be referred 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 a liver biopsy is done 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 the mouth, on the tongue, and inside the cheeks. Keeping the mouth clean is crucial to decrease the risk of infection. Artificial saliva helps with the dryness.
- Eyes: Symptoms include grittiness, burning, and itching. Your child may not produce tears when they 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 child's immune system and decrease T-cell activity. Chronic GVHD usually takes a long time to resolve, with treatment lasting months to years.
People with chronic GVHD have a higher risk of infection. If your child doesn't have GVHD, their immune system will be back to its normal infection-fighting strength approximately one to two years after the transplant. With GVHD, your child's immune system recovery will be delayed until they have completed GVHD treatment and the GVHD is resolved.
While your child has chronic GVHD, they will be given antibiotics to prevent certain infections. Contact a member of your child's healthcare team if they are exposed to chickenpox or shingles. Your child should not have immunizations with any live virus vaccines until your child is off all treatment for chronic GVHD.
Nutritional support, good hydration, physical therapy, and prevention of infection are important for complete recovery from chronic GVHD.