Graft versus Host Disease: Symptoms and treatment (GvHD)

Graft versus host disease is a reaction that occurs when the donor cells (graft) start attacking the recipient’s body. This happens in allogeneic transplants and can affect specific organs and systems such as skin, eyes, liver, lungs, and gut. To prevent GVHD, patients are prescribed immunosuppressive medications by their transplant physician.

These medications are taken for at least six months, and in some cases up to one year, depending on the patient’s condition and response to the therapy.

Types of Graft versus Host Disease

There are the following two types of Graft versus Host disease(GvHD)

Acute GVHD: Acute GVHD usually occurs just after the transplant or within six months after the transplant. Symptoms vary from mild to severe.

Chronic GVHD: Chronic GVHD occurs after six months of allogeneic transplant and remains for a long period.

Body systems affected in GVHD:

The following systems are usually affected in GVHD.

Skin Graft versus Host Disease

Gut Graft versus Host Disease

Liver Graft versus Host Disease

Lungs Graft versus Host Disease

Eyes Graft versus Host Disease

Skin Graft versus Host Disease (cutaneous GVHD)

Skin GVHD, also called cutaneous GVHD, occurs when the graft cells (donor cells) attack the patient’s skin. However, it can be acute or chronic.

Symptoms Include:

• Skin rash (whitish and reddish patches)
• Itch.
• Redness.
• Small reddish or purplish dots.
• Burning sensation in exposure to sunlight.
• Skin becomes thin or sometimes hardened.
• Darken skin

Consult your transplant physician as soon as you notice symptoms of a skin condition, so they can adjust your immunosuppressive treatment according to its severity. Moreover, the staging is made based on the extension of the rash throughout the body. The first and acute symptom of skin GVHD is palmar erythema. It is usually more prominent in people with pink skin than patients with a dark complexion.

Home Care for Skin GVHD.

As soon as your consultant makes the diagnosis of skin GVHD. The following are some home remedies to keep your skin protected.

• Drink plenty of fluids.
• Wear loose clothing.
• Wear cotton clothes.
• Keep your skin neat and clean daily.
• Avoid sun exposure, as it can worsen the burning sensation and also can make you dehydrated.
• Use moisturizing lotions on the affected area, especially at night.
•  Avoid dryness, as it can make the condition worsen.
• Use normal water for bathing, not too cold or too hot.
• Do not dry your skin by rubbing it with a bath towel; instead, dry it by gently patting it. It’s best to let it dry in the air.

Dealing with Graft versus Host Disease (Gut)

Gut GVHD occurs when the donor cells attack the cells in the gut, from the mouth to the intestines.

Symptoms of gut GVHD include. The following are the symptoms of gut GVHD.

• Loose watery diarrhea in huge amounts.
• Vomiting
• Indigestion and feeling of nausea
• Decreased appetite.
• Abdominal pain.
• Bloating.
• Weight loss.

What are the stages of gut GVHD?

Gut GVHD is graded into four stages from stage 1 to 4, depending upon the severity of loose stools and per rectal bleeding. If bleeding occurs, this is the fourth stage of gut GVHD. So, in this stage, the management is extensive, and the patient may need intensive care unit admission.

 Seeking Medical Attention:

Whenever you feel the above symptoms, the first thing that should come to your mind is gut graft-versus-host disease. As soon as you observe it, consult your transplant consultant as early as possible so that your proper treatment will not be delayed.

Avoid Dehydration in Gut GVHD:

 Severe diarrhea leads to severe dehydration and electrolyte imbalance. Try to get emergency treatment by receiving intravenous fluids and medical emergency help. You might get hospital admission, and your doctor may keep you NPO (nothing per oral) to give your gut some rest, and will start your nutrition through a drip called parental nutrition.

When to Start Your Diet?

Whenever your symptoms normalize. Start your diet in the following sequence.

 Clear Liquids:

To kickstart your diet, begin with clear liquids such as green tea, water, and certain juices. Be sure to avoid juices that contain high amounts of fiber, as they can exacerbate diarrhea. Stick to this diet for one to two days before transitioning to a full liquid diet.

 Full Liquids:

A full liquid diet contains some shakes, like banana shakes, mango shakes, etc. Remain on this diet for at least one to two days. If tolerable, then switch to a soft diet.

Soft Diet:

Start your diet with a soft diet, which includes rice, some kinds of puddings, custard, yogurt, etc.

Regular Diet:

When all the above are tolerated, come to your normal diet.

Foods to Avoid During Gut GVHD:

Foods that can worsen your GVHD are.

• Foods that contain fiber, like vegetables, cereals, and fruits.
• Avoid drinking milk.
• Avoid fatty and oily foods.
• Avoid spicy food.
• Avoid drinking alcohol. This can further affect the liver function test.
• Avoid taking more acidic drinks.
• Avoid citrus fruits.

Liver GVHD: In this type, donor cells start attacking the liver of the recipient.

Symptoms of Liver Graft versus Host Disease

The following are the signs and symptoms of liver GVHD.

Yellowish skin discoloration due to increased bilirubin in the blood. This is called jaundice.

Yellowish eyes sclera

Pain in the right upper quadrant due to enlarged liver and spleen

Swollen tummy due to an enlarged liver.

Dark yellowish urine color despite drinking enough water.

Nausea and vomiting

The liver function test shows signs of impairment.

Diagnostic tests for liver GVHD:

Liver function tests

Ultrasound of the abdomen

These symptoms may be due to any other reason; your healthcare professional will also screen you for other diseases, such as hepatitis B and hepatitis C, etc.

Is there any special test to diagnose graft-versus-host disease?

NO, there is no specific diagnostic test that could diagnose graft-versus-host disease; however, it is diagnosed based on clinical symptoms.

GVHD is managed by both immunosuppression therapy and diet control in gut GVHD. Consulting with a doctor in the early stage will lead to better management and good control. Delayed seeking medical consultation may lead to worsening of symptoms and poor prognosis.