Graft versus host disease (GvHD) is a form of the body's immune response when transplanted cells from a donor attack the cells of the recipient's body. 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 classified as 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 that contains immune system cells, such as white blood cells, for example in liver and kidney transplant procedures.
The transplant procedure is done by first examining the tissue from the donor. The goal is to see how much HLA matches (human leukocyte antigen) 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 match between the patient and the donor is large, then the risk of developing GvHD will be smaller. On the other hand, if the match is small, GvHD is at risk after the transplant procedure is performed.
The potential for an HLA match will be greater if the donor is a relative of the patient. The probability of GvHD in these conditions is only around 30–40%. However, if the donor and patient are not family members, the risk of developing GvHD is higher, ie 60–80%.
Here are other things that can increase the risk of developing GvHD:
- Elderly patient
- The transplanted organ contains a lot of white blood cells (T lymphocytes)
- Male patients with female donors who have been pregnant
- Donors bring cytomegalovirus in her body
Symptoms of Graft Versus Host Disease
Symptoms of GvHD are divided into two types based on the time of onset of symptoms, namely acute and chronic GvHD. Here is the explanation:
Graft versus host disease (GvHD) acute
Generally, in cases of acute GvHD, symptoms will appear within 100 days after transplantation. Some of the symptoms that appear in patients with acute GvHD can be:
- Dermatitis or inflammation of the skin, which is characterized by itching and redness of the skin, and a painful rash on the palms of the hands, 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 may develop chronic GvHD, which is when the symptoms of acute GvHD persist for more than 100 days.
Graft versus host disease (GvHD) chronic
Symptoms of chronic GvHD appear more than 100 days after transplantation. Based on the organ affected, some of these symptoms include:
1. Symptoms in the eye, including:
- Visual disturbance
- Irritation
- Burning feeling
- Dry eyes
2. Symptoms in the mouth and digestion, including:
- Difficulty swallowing
- Mouth feels very dry
- Too sensitive to hot, cold, spicy and sour food
- 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 the 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
- Thickened skin
- Nails that are thickened and break easily
- Broken sweat glands
- Changed skin color
- Hair loss
6. Symptoms of the genitals
- Vaginal itching, dryness, and pain
- Itchy and irritated penis
When to go to the doctor
All patients who have had a transplant need to monitor for symptoms of GvHD for at least 1 year after surgery. Therefore, patients need to have regular check-ups and tell their doctor if they experience the above symptoms. However, if the symptoms experienced are very bothersome, you can immediately go to the ER.
Diagnosis of graft versus host disease
To diagnose GvHD, the doctor will ask questions about:
- Time for transplant
- Time of first appearance of symptoms
- What symptoms do you feel?
After that, the doctor will observe the symptoms that appear in the patient's body. If symptoms occur on the skin, the doctor will take a sample of skin tissue 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 inspections include:
- Blood tests, to see the number of blood cells, including immune cells, and blood electrolyte levels
- Liver ultrasound and liver function tests
- Kidney ultrasound and kidney function tests
- Lung function test
- Schirmer's test, to see how the tear glands work
- Test barium swallow, to see the condition of the digestive tract
Graft Versus Host Disease Treatment
GvHD will generally recover on its own within a year or so after the transplant is performed. However, patients still need to take medication to control their symptoms.
The treatment given by the doctor is the administration of corticosteroid drugs, such as prednisolone and methylpredinisolone. If corticosteroids are not able to relieve symptoms, doctors will combine them with immunosuppressive drugs, such as:
- Cyclosporine
- Infliximab
- Tacrolimus
- Mycophenolate mofetil
- Etanercept
- Thalidomide
The above medicines can lower 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 treatment, patients also need to perform self-care, including:
- Using eye drops to treat dry eyes
- Using mouthwash to relieve dry mouth and sore mouth
- Using corticosteroid cream to treat itching and redness on the skin
- Use moisturizing lotion or cream regularly to keep skin moisturized
- Avoid excessive sun exposure and use 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
- Avoid activities that increase the risk of infection, such as contact with animal waste, 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)
- Pleurisy (inflammation of the lining of the lungs)
- Pneumonia (inflammation of the lungs)
- Thrombocytopenia
- Anemia
- heart failure
- Hemolytic-uremic syndrome
In addition, patients who have GvHD and take medication to control their symptoms are at a higher risk of developing an infection, even if they are receiving antibiotics.
Prevention of Graft Versus Host Disease
There is no method that can definitively prevent GvHD. However, there are actions that doctors can take to reduce the risk of GvHD in patients undergoing transplantation, including:
- Performing the technique of removing T lymphocyte cells from donor organs
- Ensuring that donors come from families
- Using the patient's umbilical cord blood as a donor if the patient has it
- Giving immune system-suppressing drugs after transplantation, such as cyclosporine, methotrexate, tacrolimus, and mycophenolate mofetil
