Running head: GRAFT VERSUS HOST DISEASE

A Glimpse into Graft Versus Host Disease

Kaylee Blankenship
California State University, Stanislaus

GRAFT VERSUS HOST DISEASE

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 donors 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 hosts antigen presenting cells,
which in turn activate the donors 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 hosts body.
The migration of these cells also results in the activation of leukocyte subsets (Ram & Storb,
2013). These T cells see the persons 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 patients 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 patients 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).

GRAFT VERSUS HOST DISEASE

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 patients 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 donors cells are attacking the hosts 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

GRAFT VERSUS HOST DISEASE

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 bodys 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 patients 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 patients 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 patients life is even more discouraging. Nurses need to be there
for there patients, providing teaching and advocating for them every step of the way through this
disease in order help improve the patients overall well being.

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7
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.