Graft versus host disease (GvHD) is a form of the body's immune response when graft cells originating from a donor attack the recipient's body cells. This condition is a common side effect experienced by patients after undergoing a transplant.
GvHD that appears in each person can be different. In GvHD which is relatively mild, the condition can recover by itself. However, in some cases, GvHD can cause severe and dangerous symptoms that require serious treatment.
Causes of Graft Versus Host Disease
Graft versus host disease is a form of the body's immune response that arises as a result of the attack of graft cells from the donor to the patient's body cells. This condition is a side effect that can be caused by:
- Bone marrow transplant surgery , which is usually performed on blood cancer and lymphoma patients
- Internal organ transplant surgery containing immune system cells, such as white blood cells, for example in liver transplant and kidney transplant procedures .
The transplant procedure is carried out by first examining the tissue from the donor. The goal is to see how compatible the HLA ( human leukocyte antigen ) is with the patient's host cells. HLA itself is a molecule that has an important role in the immune response to foreign substances in the body.
If the HLA matches between patients and large donors, then the risk of developing GvHD will be smaller. Conversely, if the match is small, there is a risk of GvHD occurring after the transplant procedure.
The potential for HLA compatibility will be greater if the donor is the patient's family. The possibility of GvHD in these conditions is only around 30–40%. However, if the donor and patient are not family, the risk of developing GvHD is higher, which is 60–80%.
The following are other things that can increase the risk of developing GvHD:
- Elderly patient
- The transplanted organ contains many white blood cells (T lymphocytes)
- The patient is male with a female donor who has been pregnant
- The donor carries cytomegalovirus in his body
Symptoms of Graft Versus Host Disease
GvHD symptoms are divided into two types based on when symptoms appear, namely acute and chronic GvHD. The following is an explanation:
Acute graft versus host disease (GvHD).
Generally, in cases of acute GvHD, symptoms will appear within 100 days after transplant. Some of the symptoms that appear in acute GvHD sufferers can include:
- Dermatitis or inflammation of the skin, characterized by itching and redness of the skin, and a painful rash on the palms, ears, face or shoulders.
- Hepatitis , which can be characterized by yellowish eyes and skin, dark urine, and pale stools
- Enteritis, which is characterized by diarrhea, nausea, vomiting, abdominal pain, cramps, and bloody stools
- Anorexia (decreased appetite) and weight loss
- Fever
In some cases, people with acute GvHD can experience chronic GvHD, which is when acute GvHD symptoms persist for more than 100 days.
Chronic graft versus host disease (GvHD).
Symptoms of chronic GvHD appear more than 100 days after the transplant. Based on the organs affected, some of these symptoms include:
1. Symptoms in the eye, including:
- Impaired vision
- irritation
- Burnt taste
- Dry eyes
2. Symptoms in the mouth and digestion, including:
- Difficulty swallowing
- Mouth feels very dry
- Overly sensitive to hot, cold, spicy and sour foods
- Tooth decay
- Bleeding gums
- White patches in the mouth
- Pain in the mouth and stomach area
- Loss of appetite
- Jaundice (jaundice)
- Weight loss
3. Symptoms in the lungs and breathing, which are characterized by symptoms of obstructive pulmonary disease, namely:
- Wheezing
- Hard to breathe
- Prolonged cough
4. Symptoms in joints and muscles, in the form of:
- Muscle cramp
- myalgia
- Arthritis in the joints
5. Symptoms in the skin and hair, including:
- Rash and itching
- Thick skin
- Nails that are thick and break easily
- Sweat glands are damaged
- Skin color changes
- Hair loss
6. Genital symptoms
- Vagina itching, dryness and pain
- Itchy and irritated penis
When to see a doctor
All patients who have had a transplant need to watch for symptoms of GvHD for at least 1 year after surgery. Therefore, patients need to carry out routine controls and notify the doctor if they experience the above symptoms. However, if the symptoms are very disturbing, you can immediately go to the emergency room.
Diagnosis of Graft Versus Host Disease
To diagnose GvHD, the doctor will ask questions about:
- Time of transplant
- Time of first symptom appearance
- What symptoms are felt
After that, the doctor will observe the symptoms that appear in the patient's body. If symptoms occur in the skin, the doctor will take a skin tissue sample to be examined in the laboratory by a pathologist .
Several tests can also be performed to assess the condition of the internal organs that may be affected by the GvHD reaction. These checks include:
- Blood test, to look at the number of blood cells, including immune cells, and blood electrolyte levels
- Liver ultrasound and liver function tests
- Renal ultrasound and kidney function tests
- Lung function test
- Schirmer's test, to see how the tear glands work
- Barium swallow test , to see the condition of the digestive tract
Graft Versus Host Disease Treatment
GvHD usually gets better on its own within a year or so after the transplant. However, patients still need to undergo treatment to control their symptoms.
The treatment given by the doctor is the administration of corticosteroid drugs, such as prednisolone and methylpredinisolone. If corticosteroids are unable to relieve symptoms, the doctor will combine them with immunosuppressive drugs , such as:
- Cyclosporine
- Infliximab
- Tacrolimus
- Mycophenolate mofetil
- Etanercept
- Thalidomide
The above drugs can decrease the immune system's ability to fight infection. In addition, the doctor will also prescribe antibiotics to minimize the risk of infection.
In addition to the above treatments, patients also need to perform self-care, including:
- Use eye drops to treat dry eyes
- Using mouthwash to relieve dry mouth and sore mouth
- Using corticosteroid creams to treat itching and redness on the skin
- Use moisturizing lotions or creams regularly to keep your skin moisturised
- Avoiding excessive sun exposure and using sunscreen to prevent worsening of GvHD symptoms on the skin
- Maintain a healthy diet and avoid consuming foods that can irritate the digestive tract, such as sour and spicy foods
- Avoiding activities that may increase the risk of infection, such as contact with animal feces, tending livestock or gardening
- Exercise regularly
In severe cases, GvHD patients may need to be hospitalized for more intensive treatment and monitoring. The patient may also need a feeding tube to get adequate nutrition.
Complications of Graft Versus Host Disease
Complications that can arise due to GvHD can occur differently in each sufferer. The following are complications that are at risk of arising from GvHD:
- Pericarditis (inflammation of the lining of the heart)
- Pleuritis (inflammation of the lining of the lungs)
- Pneumonia (inflammation of the lungs)
- Thrombocytopenia
- Anemia
- Liver failure
- Hemolytic-uremic syndrome
In addition, patients who have GvHD and are taking drugs to control their symptoms are more at risk of developing an infection, even though they are already receiving antibiotics.
Prevention of Graft Versus Host Disease
There is no method that can definitely prevent GvHD. However, there are actions that doctors can take to reduce the risk of GvHD in patients undergoing transplants, including:
- Performing techniques for removing T lymphocyte cells from donor organs
- Strive for donors come from the family
- Using the patient's cord blood as a donor if the patient has it
- Administering drugs that suppress the immune system after the transplant, such as cyclosporine, methotrexate , tacrolimus , and mycophenolate mofetil