Running head: GRAFT VERSUS HOST DISEASE  

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A Glimpse into Graft Versus Host Disease

Kaylee Blankenship

California State University, Stanislaus

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A Glimpse into Graft Versus Host Disease

Cancer is the second leading cause of death in the United States, which makes it a

common health issue that nurses come across in their practice (Centers for Disease Control and

Prevention, 2013). There are numerous types of cancer, cancer treatments, and side effects from

these treatments that nurses need to be aware of in order to provide quality care to their patients.

For certain types of cancers, transplants are a necessary part of treatment, such as a bone marrow

transplant. As is the case with almost every treatment option, there are potential complications.

Graft versus host disease (GVHD) is one serious and possibly fatal complication of this

treatment process that patients and nurses need to be knowledgeable of, so that it can be

addressed quickly and effectively. Through this paper, the reader will gain knowledge regarding

the causes and pathophysiology of graft versus host disease. The reader will also better

comprehend the medical treatments and management of the disease, in addition to, the nursing

diagnoses and patient teaching associated.

Etiology and Pathogenesis

GVHD is a complication that can occur after an allogeneic stem cell or bone marrow

transplant takes place. It is basically an immune reaction of the donor’s cells against the patients’

cells and tissues (Stanford Hospital and Clinics, 2012). The pathogenesis of this disease involves

a few simple steps. First, tissue damage occurs along with the release and proliferation of

cytokines (Ram & Storb, 2013). These cells then trigger the host’s antigen presenting cells,

which in turn activate the donor’s T cells. This activation results in the proliferation of T cells, a

type of white blood cell, which then migrates to multiple target tissues within the host’s body.

The migration of these cells also results in the activation of leukocyte subsets (Ram & Storb,

2013). These T cells see the person’s body as foreign and begin an immune reaction (Stanford

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Hospital and Clinics, 2012). The migration of all of the cells throughout the patient’s body is

what causes the range of clinical manifestations seen in GVHD.

There are two types of GVHD: acute and chronic. According to Baker and McKiernan,

“the incidence of acute and chronic GVHD is about 30%–60% and carries a mortality rate of

50%” (2011). Acute GVHD appears within 100 days following the transplant and targets the

liver, skin, and gastrointestinal (GI) tract (Baker, 2010). The symptoms that occur can vary from

very mild, to severe, and even fatal. The onset of these symptoms occurs rapidly, so it is

imperative that detection is quick so that treatment can begin (Stanford Hospital and Clinics,

2012).

Chronic GVHD, on the other hand, occurs after the first 100 days following the transplant

and the onset of symptoms is typically more gradual. The outlook for chronic GVHD is better

than that of acute, with mild symptoms that are rarely fatal (Stanford Hospital and Clinics, 2012).

The organ systems that chronic GVHD affects are also more extensive and variable. They

include, the skin, mouth, eyes, liver, GI tract, lungs, muscles, and vagina (Baker & McKiernan,

2011).

Clinical Significance and Medical Management

The diagnosis of GVHD is typically based on the patient’s presenting clinical

manifestations (Dignan et al., 2012). The skin is normally the first organ system affected. A

maculopapular or pruritic rash appears starting on the soles and palms and progressively spreads

to the rest of the body. A cutaneous biopsy may need to be preformed in order to help confirm a

diagnosis of GVHD and rule out other causes of the integumentary clinical manifestations

(Dignan et al., 2012).

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The next organ system to be affected is the GI tract. Patients with GVHD frequently

experience nausea, vomiting, weight loss, anorexia, abdominal pain, and diarrhea (Dignan et al.,

2012). Excessive diarrhea is the main complication of the GI system that it is important for the

nurse to monitor the patient for bloody stools as a result of mucosal ulceration. In this case, an

endoscopy would be beneficial in order to determine the extent to which the GI tract has been

affected by GVHD. During the endoscopy, the physician may take biopsies to aid in ruling out

other possible diagnoses. Additional imaging of the GI system may also be performed in order to

visualize how the bowels may be affected by GVHD. Images could possibly display increased

air or fluid levels indicating an ileus, dilation of the lumen, or wall thickening in the small bowel

(Dignan et al., 2012).

A third organ that is affected by GVHD is the liver. According to Dignan et al., the

patient, “typically presents with jaundice and a cholestatic pattern of liver injury including

elevated conjugated bilirubin, alkaline phosphatase and gamma-glutamyl-transpeptidase” (2012).

Therefore, it is important to also perform a full lab panel on these patients in order to determine

the extent to which the patient’s liver is being affected, and treat accordingly. Other clinical signs

of GVHD involving the liver that the patient could possibly display include fluid retention, dark

urine, pale stools, and pain related to hepatomegaly (Dignan et al., 2012).

All of the aforementioned clinical manifestations are a result of GVHD. Since this

disease is a type of immune reaction in which the new donor’s cells are attacking the host’s cells,

it is treated accordingly with immunosuppressants (Stanford Hospital and Clinics, 2012).

Treatment may include a single medication, but typically includes multimodality regimens. The

medications prescribed for treatment may incorporate cyclosporine, prednisone, cellcept,

tacromilus, and topical therapy for the rashes that occur (Baker, 2010). For chronic GVHD

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treatment using immunosuppressive medications usually lasts for about two to three years on

average (Baker & McKiernan, 2011). Side effects resulting from treatment with corticosteroids

may include osteoporosis, insomnia, diabetes mellitus, infections, hypertension, and frequent

emotional changes (Baker & McKiernan, 2011). Infection is the most common side effect and is

a leading cause of death in patients with GVHD (Stanford Hospital and Clinics, 2012). GVHD

causes the break down of the bodies natural barriers making it easier for bacteria and other

infectious agents to invade the body. So, when patients are prescribed an immunosuppressive to

combat the GVHD, they are making their bodies even more susceptible to infection, weakening

the body’s defenses even further (Stanford Hospital and Clinics, 2012). Alternative therapies to

immunosuppressants have been used with varying success. Some of these treatment options

include mycophenolate mofetil, extracorporeal photophoresis, calcineurin inhibitors,

immunoglobulins, and topical applications (Baker & McKiernan, 2011).

Nursing Diagnoses and Patient Teaching

There are numerous nursing diagnoses that apply to patients experiencing GVHD. They

can range from more severe, such as infection, to more mild psychosocial issues, such as

ineffective coping, depending on the type and severity of GVHD. A few selected nursing

diagnoses related to GVHD are: (a) infection related to immunosuppression caused by treatment,

(b) imbalanced nutrition: less than body requires related to GI irritation, (c) impaired skin

integrity related to maculopapular and/or pruritic skin rash, (d) pain related to hepatomegaly and

other symptoms of GVHD, and (e) ineffective coping related to acceptance of illness and

outlook. This wide variety of nursing diagnoses is listed in the order of priority of action.

Depending on the type and severity of GVHD the patient is experiencing, these diagnoses may

be modified in order to more accurately reflect the patient’s particular condition.

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Oncology nurses are key players in aiding patients with GVHD to manage their

symptoms and preventing further complications. There are many topics that need to addressed by

the nurse when conducting patient teaching regarding GVHD symptoms, diagnosis, and

treatment. Patient teaching subjects should include proper care of the catheter site, use of sun

block whenever outside, possible complications of GVHD, and any dietary modifications that

need to be made (Baker & McKiernan, 2011). Since the main complication of GVHD is

infection, one of the crucial teaching topics to emphasize with patients is how to prevent

infection. Nurse should explain to patients how increased frequency of hand washing, staying

away from crowded places, and thoroughly cooking all food products are possible ways of

preventing infection (Stanford Hospital and Clinics, 2012). Instruction on the medications used

for treatment and promoting strict adherence to the medication regimen is also imperative to

patient health outcomes. Nurses should also explain to patients what side effects they should be

watching for and when to report side effects to the doctor. Some of these side effects include

diarrhea, tremors, tarry colored stools, nausea, and vomiting (Stanford Hospital and Clinics,

2012). Nurses caring for patients with GVHD, and patient’s in general, should continually be

advocating for their patients and promoting patient comfort.

It is clear the GVHD can be a debilitating and even fatal disease, however, there are ways

to manage and treat it. The first step is to determine the type of GVHD and which body systems

the disease seems to be affecting the most. As mentioned previously, these are usually the skin,

GI tract, and liver. Experiencing cancer is hard alone, but acquiring GVHD after a transplant that

was supposed to help better the patient’s life is even more discouraging. Nurses need to be there

for there patient’s, providing teaching and advocating for them every step of the way through this

disease in order help improve the patient’s overall well being.

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References

Baker, M. (2010). Graft-versus-host disease following autologous transplantation. Oncology

Nursing Forum, 37(3), 269-273.

Baker, M., & McKiernan, P. (2011). Management of chronic graft-versus-host disease. Advanced

Practice Nursing Issues, 15(4). doi: 10.1188/11.CJON.429-432

Centers for Disease Control and Prevention. (2013). Leading causes of death (NVSR 64-2).

Retrieved from http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

Dignan, F., Clark, A. Amrolia, P., Cornish, J., Jackson, G., Mahendra, P., Scarisbrick, J., Taylor,

P., Hadzic, N., Shaw, B. E., & Potter, M. N. (2012). Diagnosis and management of acute

graft-versus-host disease. British Journal of Haematology, 158, 30-45. doi:

10.1111/j.1365-2141.2012.09129.x

Ram, R., & Storb, R. (2013). Pharmacologic prophylaxis regimens for acute graft-versus-host

disease: Past, present, and future. Leukemia & Lymphoma, 54(8), 1591-1601. doi:

10.3109/10428194.2012.762978

Stanford Hospital and Clinics. (2012). Blood and Bone Marrow Transplant Program. Stanford,

CA: Stanford University Medical Center.