If you have bone marrow or blood cancer, you might receive a bone marrow transplant
as part of your treatment. Unfortunately, this life-saving procedure sometimes comes with a complication called Graft Versus Host Disease
. Here’s what you should know about this common issue.
What is Graft Versus Host Disease?
Whenever you receive a transplant from another person—whether it’s a tissue (like skin and muscle) or a larger organ (like a kidney), there’s a risk of “rejection.” This simply means that your body doesn’t “get along” with the new transplant, and may even attack it. Graft Versus Host Disease (GvHD) is a similar problem.
During a transplant, you may receive bone marrow or blood stem cells from another person—a so-called “allogeneic transplant.” These cells are used to restart the function of your bone marrow after high doses of chemotherapy and/or radiation therapy. But in some cases, the transplanted cells attack your body, causing a range of health problems.
GvHD can cause issues in almost any part of your body, including your skin, eyes, mouth, lungs, stomach, intestines, nerves, and genitals. It’s very common, occurring in up to 70%
of bone marrow transplant recipients. GvHD can be deadly if not treated properly, so let your care team know immediately if you have any symptoms or concerns.
What are the symptoms of GvHD?
GvHD can cause a wide range of varied symptoms. The specifics will depend on whether you have acute or chronic GvHD and where in the body it is presenting itself.
Acute GvHD usually develops within 100 days of the transplant procedure. The symptoms tend to come on all at once, and are most likely to show up in one of these areas:
- Skin: An itchy, red, and painful rash that may appear on your palms, the soles of your feet, arms and legs, torso, or elsewhere. Blistering and flaking are possible.
- Digestive system: Nausea, diarrhea, vomiting, cramping, and other digestive problems.
- Liver: Issues with your liver—i.e. hepatitis—can cause jaundice. This is a yellowing of your eyes and skin.
Chronic GvHD usually occurs later, even years after transplant, and can last many years or decades. It can also affect many different body parts, including:
- Skin: A mild or serious rash, redness or changes in skin color, skin that’s dry and itchy, hardened or thickened skin, and changes in your sweating.
- Mouth: Very dry mouth, mouth sores / ulcers, difficulty eating, gum disease, and tooth decay.
- Genitals: Itching, pain, and scarring of the penis, scrotum, and vagina.
- Hair & nails: Brittle nails, loss of nails, loss of head / body hair, premature gray hair.
- Digestive tract: Nausea, diarrhea, vomiting, cramping, loss of appetite, weight loss.
- Liver: Jaundice, swelling in the abdomen, elevated liver enzymes.
- Muscles & joints: Stiffness, weakness, cramps, and mobility/flexibility issues.
Who’s at risk for GvHD?
When you’re receiving a transplant, the donor should be as genetically close to you as possible. After all, GvHD is caused by a “mismatch” between the host (that’s you) and the donor (whom the cells are taken from). The more similar your bodies are, the less likely you are to develop GvHD.
For this reason, your healthcare team will try to take donor cells from a sibling, or another close family member (like a parent or adult child). They’ll also run tests to determine who’s the best possible match (more on that shortly). Getting a bone marrow or stem cell transplant from someone who’s not a good match—such as a stranger—is a risk factor for GvHD.
Other risk factors include:
- Getting donor cells from someone who was pregnant in the past
- Having had acute GvHD in the past
- Advanced age of either the donor or the recipient
How is GvHD prevented?
After surgery, your healthcare team will probably give you medication to suppress your immune system. These “immunosuppressant” drugs (such as cyclosporine, tacrolimus, and sirolimus) dampen activity in your new, transplanted T-cells, making them less likely to attack the rest of your body. You’ll likely take these medications for about a year after your transplant. At that point, your team will gradually lower the dose and see how your body reacts.
Finding the right match
As we mentioned above, one of the best ways to prevent GvHD is to choose the right donor. To do this, your healthcare team will run a blood test to determine your Human Leukocyte Antigen (HLA) type. They’ll also test potential donors (like siblings from your same two parents) to find the best match.
If you don’t have a close match available to donate bone marrow or stem cells, your healthcare team may be able to offer a different procedure called “haploidentical transplant.” This newer treatment can use transplanted cells from a wider group of donors (such as your biological parents or adult children, who by definition are a half or “haplo” match), making it easier to find a match.
You may also have the option to use “cord blood.” Blood from the umbilical cords of healthy newborns is rich in stem cells, and contains fewer of the T-cells associated with GvHD.
Lastly, removing T-cells from the transplant product that will be infused can sometimes lower the chances of GvHD. Unfortunately, this can also lead to more bacterial infections after treatment, and may make cancer relapses more likely. Research is ongoing, but it’s an option your healthcare team might consider.
How is GvHD treated?
The biggest tool doctors use for treating GvHD is a class of drugs called corticosteroids. These drugs suppress your immune system, and reduce inflammation. But how corticosteroids are used can vary greatly, depending on your medical background and current health status.
If you have a mild form of GvHD (for instance, a skin rash), your doctor may simply prescribe a topical steroid cream and see how the rash responds. Similarly, if GvHD is affecting your eyes, a steroid eye drop solution might be prescribed.
On the other hand, if you have a more serious form of GvHD (one that affects your whole body or multiple organ systems) your doctor may prescribe a stronger corticosteroid like prednisone or methylprednisolone. You may take these medications orally, as a pill, or you may need to stay in the hospital to receive IV infusions. These first-line responses to GvHD are often effective, but typically come with side effects like weight gain, insomnia, depression, high blood pressure, blood sugar fluctuations, bone thinning, and mood swings.
If corticosteroids aren’t effective, your doctor may prescribe a “second-line treatment.” There are many medications that fill this role, including ruxolitinib (brand name Jakafi), ibrutinib (brand name Imbruvica), and mycophenolate mofetil.
Finally, your care team might also suggest some supportive treatments to strengthen your overall health. These can include bone-strengthening medications (to prevent steroids from weakening your bones), IV nutrition procedures to make sure you’re well nourished, and antimicrobials to stave off infections while your immune system is suppressed.
Self-care and what to watch out for
If you’re at risk for GvHD or have already been diagnosed, our number one suggestion is to work closely with your healthcare team! Take prescriptions exactly as your doctor recommends, and let your team know at the very first sign of new symptoms or other changes. Even things that seem small or embarrassing can spiral into life-or-death issues, so don’t hold anything back. The sooner you identify a problem, the better your health outcomes will be.
It’s also important to limit your direct sun exposure. GvHD may be triggered by the sun’s UV rays, so stay covered up and use a high-SPF sunscreen when you’re out and about.