After an allogeneic transplant, there is a complication that may occur. It is called graft vs host disease (GvHD). This is one of the common problems that affect people after a stem cell transplant, where the cells of a donor are used. Living with graft vs host disease can be emotionally stressful for the patient as well as their family.The complication may occur in a few months or years following the transplant. Nearly 50% of patients who have received a transplant can have GvHD. A majority of the time, this problem is moderate and may improve after a while.
Medical practitioners use allogeneic stem cell transplantation for curing blood cancers. It is even used for treating certain types of blood disorders. At the time of an allogeneic transplant procedure, the practitioner transplants hematopoietic stem cells from a donor into your body. At last, these stem cells turn into mature blood cells. Read further to learn what is graft vs host disease, as well as its causes, signs, and treatment.
Graft Vs Host Disease: An Overview
Graft Vs Host Disease or GvHD is a problem that occurs after a stem cell transplant. Patients go for a stem cell transplant with blood or bone marrow to refill their cell counts. In general, this is carried out after treating a cancer. Over 50 % of the individuals who are recipients of stem cell transplants have higher chances of the attack from the donated cells on their body. This is what we call GvHD. Let us now talk about the types of Graft vs Host Disease.
Different Types of Graft vs Host Disease
Chronic graft versus host disease and acute graft versus host disease are the two main types of GvHD. Here is a brief description of these:
Chronic Graft Versus Host Disease
Chronic Graft Versus Host Disease may occur at any time after an allogeneic transplant. However, a majority of cases begin within a couple of years. The condition may impact your mouth, lungs, muscles, skin, genitals, and many other areas.
Acute Graft Versus Host Disease
Acute Graft Versus Host Disease usually happens right after your transplant. It might occur within the initial 100 days. The patient may observe the signs of the condition afterward. It can impact your skin, liver, or gastrointestinal tract.
Graft Vs Host Disease Cause
Most individuals who have undergone a transplant may have a higher chance of developing Graft Versus Host Disease. In this instance, white blood cells (WBCs), the T-cells in the donated bone marrow or stem cells, aim to destroy the host cells. They identify them as aliens.
T-cells can identify which cells are the same as themselves. They even recognize those that are distinct and don’t have the same genetic indicators. Human leukocyte antigens, or HLA, are the genetic indicators on cells that give them their tissue type. HLA are like your fingerprints; no two people have similar HLA unless they are identical twins.
GvHD, in some cases, can start in the first 100 days following the transplant. A chronic type of GvHD may appear following 100 days. It can sometimes even happen up to a year or more post-transplant. It may stay within the patient for a long time. The areas where acute and chronic GvHD occurs are the skin, liver, and GI tract.
Graft Vs Host Disease Symptoms
Both acute and chronic types of GvHD show mild to severe symptoms. The areas that acute GvHD mainly affects include the skin, liver, intestines, and immune system. Common symptoms of acute GvHD are:
- Jaundice
- Skin rash
- Increased risk for infections
- Abdominal pain or cramps
- Nausea or vomiting
- Loss of appetite
- Diarrhea
- Abnormal liver function
Chronic GvHD generally begins more than three months post-transplant. It can remain in the body for life. The symptoms of this type of GvHD may include:
- Weight loss
- Vaginal dryness
- Dry eyes, changes in vision
- Joint pain or stiffness
- Reduced bile flow from the liver
- Shortness of breath because of lung damage
- Dry mouth, white patches inside the mouth
- Muscle weakness
- Brittle hair and early graying
- Reduced bile flow from the liver
- Fatigue or chronic pain
How Is GvHD Diagnosed?
Those having acute graft vs host disease symptoms might undergo various tests to confirm the diagnosis and exclude other conditions mimicking acute GvHD. Medical experts use many lab tests to diagnose problems caused by Graft Versus Host Disease. Here are examples of these tests:
Biopsy
The doctor takes a small tissue sample from the affected portion of the patient’s body. They send the sample to the laboratory. This helps the pathologist to observe the sample under a microscope. It might take some time to get the outcomes.
The biopsy you receive will depend on the affected body part. You may go through a liver or skin biopsy. A liver biopsy is done with a CT scan or ultrasound. The healthcare provider will use images from the ultrasound or CT scan to guide the biopsy needle in an accurate location within the liver. As you receive local anesthesia, they will place a needle through your skin and into the affected part of the liver. The samples of the tissue will be taken.
Following the biopsy, you may need to stay in the hospital facility for a while or maybe for an entire night.
In a skin biopsy, you’ll get local anesthesia that will numb your skin. After that, the doctor will take a small sample of the affected skin. They will also place a dressing on the site of the biopsy.
Endoscopy
If your doctor suspects you have GvHD in your digestive tract, you may need an endoscopy. When doing the endoscopy, a doctor can perform a biopsy. This test aims to let the doctor look into your esophagus and stomach through a tube.
Lung Function Tests
If your lungs show signs of GvHD, you can go for tests to see how your lungs are working. Various types of lung function tests are there. Some show how well your lungs absorb oxygen and how much air the patient inhales or exhales.
X-ray
The doctors may also perform an X-ray or CT scan of your lungs. In comparison to other diagnostic methods, X-rays are painless. Also, the patient doesn’t need to do any preparation for this.
Other tests to carry out the diagnosis of GvHD include a biopsy of the skin and mucous membranes.
Also Read: WHAT IS MANTLE CELL LYMPHOMA? CAN IT BE CURED?
Who Is At More Risk Of GvHD?
Those with suppressed immunity and who get white blood cells from another person are more at risk of GvHD. In other cases, GvHD may occur due to:
Mismatched Related Transplants
There are situations where the donor and host are related but not as compatible as identical twins. However, the donor T-cells may still see the host cells as distinct and could be hazardous. To make transplantation happen, there could be a mismatch in HLA-A, HLA-B, and HLA-DR. However, the chances of GvHD are higher than matched related donors and hosts.
Female-To-Male Mismatch Transplants
Compared to females, a male is likely to produce a greater number of CD34+ stem cells. This makes male donors preferable to HSCT donors. CD34+ stem cells may change into more than one cell type.
Female donors also provide lymphocytes carrying memory traits. They may have a memory of any pregnancy, making transplantation harder. This is due to the differences in the genders.
Very Insensitive Conditioning Pre-Transplant
The risks of graft vs host disease can be the higher dosage of chemotherapy and radiotherapy. Before transplantation, the patient might have undergone these procedures to destroy their own bone marrow cells. The aim of this can be to make these cells more receptive to the donor bone marrow cells. This may result in weakness as the patient’s immune cells have been devastated. The same may happen with those who have received a mini transplant.
Viruses
Following transplantation, a viral or fungal infection can be a greater risk. This is likely to happen because the patient lacks immune cells to combat disease. The patient should be kept in isolation to reduce the risk.
Associated with the herpes virus, cytomegalovirus may impact HLA expression and elevate the danger of GVHD, be it acute or chronic. Moreover, it may set off infections like gastroenteritis, hepatitis, and pneumonia. The chickenpox and herpes zoster virus may also result in the same complications.
Racial Mismatch Transplants
If a donor is from a distinctive race, it can be a sign of danger. This is because it becomes complicated to match HLA. It can also be tough to locate good tissue type matches for those belonging to minority groups. The reason for this is the limited population of these people.
Unrelated Donor Transplants
If a host undergoes an unrelated donor transplant, the T-cells will recognize host cells as alien to their own. Serious GvHD can happen due to this since a distinct HLA is involved. The donor’s tissue type will go through an assessment to check whether there are any matches. Doctors will select donors based on their picks for HLA-B, HLA-C, HLA-A, and HLA-DRB1.
What Is The Graft Vs Host Disease Survival Rate?
According to researchers, those suffering from serious acute GvHD had a survival rate of 62% in the 1st year. On the other hand, 49% had 2 years, and 47% had 3 years survival rates.
Those suffering from serious acute GvHD from 2016 to 2017 had an improved GvHD survival rate than patients who had it from 2005 to 2015.
GvHD survival rate depends on numerous factors. These can include the patient’s overall wellness, age, and the severity of the condition. Overall, transplant survivorship has been growing. However, the patterns and the level at which GvHD affects post-transplant mortality are under investigation. Severe cases of GvHD tend to have lower survival rates. It also includes those with diarrhea, liver or lungs affected, or extensive skin involvement.
What Questions Should Be Asked of the Doctor Before Treatment?
Graft vs host disease is a serious and complicated ailment. If you are suffering from it, you may be seeking treatment. But you may also have questions regarding the same. Here is a list of questions you should ask your doctor before getting started:
- How much time will the specific type of GvHD last?
- Am I a suitable candidate for a clinical trial for new medication?
- How many follow-up visits do I need?
- Will a team of experts assist in monitoring the various organs affected?
- What are the worsening signs, and when should I report them?
- What should I do to enhance my quality of life?
Graft Vs Host Disease Treatment
Patients having GvHD have a weaker immune system and may even experience some signs of infection. Their healthcare provider may recommend certain drugs to suppress their immune system. This will avert the donated cells or graft from attacking your body. What type of drugs you will have to take to treat the condition will depend on the site and the extent of its severity. Here are the drugs that you are most likely to take:
- Ciclosporin
- Monoclonal antibodies
- Steroids
- Tacrolimus
- Light treatment
- Newer drugs for GvHD
- Thalidomide
- Methotrexate
Your healthcare provider can offer the most suitable graft vs host disease treatment depending on the condition you are suffering from.
The provider will prescribe treatment for GVHD, depending on the severity of the condition. Those having mild symptoms affecting the skin might take a steroid skin cream along with immunosuppressants. Patients having serious systematic or bodywide acute GvHD may take another corticosteroid along with the immunosuppressant drugs.
You may have to take the following treatment for Chronic GVHD:
The treatment for mild cases of chronic GvHD may emphasize a particular organ, such as the eyes or the skin. Healthcare providers may prescribe a systematic or whole-body treatment for severe chronic GvHD (affecting multiple body organs). As per the Food and Drug Administration (FDA), three drugs are highly effective following steroid therapy. These are ruxolitinib, belumosudil, and ibrutinib. Other tried and tested treatments for chronic GvHD may include extracorporeal photopheresis, mesenchymal stromal cells, and extracorporeal photopheresis.
What Are The Preventive Measures For GvHD?
A doctor will take certain steps before and just after the transplantation to lessen your danger of Graft Vs Host Disease. For most individuals, you may receive prophylactic treatment with a mix of cyclosporine and methotrexate.
It even incorporates antiviral, antibacterial, and antifungal treatments to reduce the danger of getting infected.
Your doctor may also ensure that you and your donor are the perfect match for each other. This will also help reduce the risk of complications. Human leukocyte antigens are often used to determine a good match.
Is GvHD Life Threatening?
The most serious GvHD cases can be life-threatening. Signs impacting the musculoskeletal system and the lungs can be hazardous. So, it is wise to get a treatment before the problem advances.
In a 2019 study, it was found that the rate of survival has risen recently because of advanced treatments and care. At present, 2 out of 3 people suffering from severe GvHD live for two years following the initial development of the ailment.
Conclusion
GvHD is a serious ailment that can be life-threatening. In this, the donor cells ward off the healthy cells of the recipients following a stem cell transplant. This condition is likely to be acute or chronic, resulting in various medical issues. But you can seek a variety of treatment options for GvHD. Make sure to speak with your doctor to understand the risks of transplantation.
University Cancer Centers are the ideal place to get the most effective treatment for graft vs. host Disease. For every cancer patient, we offer an accurate diagnosis and necessary assistance.
