Types and grades of GvHD

Graft versus host disease (GvHD) is a complication that can happen after a stem cell transplant from a donor.

There are different types of GvHD. The type depends on several things, including how long after your transplant the GvHD starts.

Your doctor works out the type you have and gives it a grade. To find the grade, they look at the organs involved and how affected they are.

Knowing the type and grade of GvHD helps doctors plan your treatment. 

Types of GvHD

Finding the type of GvHD involves looking at the:

• timing of when the GvHD started
• areas of the body affected by the GvHD
• signs and symptoms of GvHD

Knowing the type of GvHD helps doctors to make treatment decisions.

There are 2 main types of GvHD. They are:

• acute GvHD
• chronic GvHD

Overlap syndrome is when you have symptoms of both types.

Another type is persistent, recurrent or late onset acute GvHD.

Acute GvHD

Acute GvHD generally starts within 100 days of your transplant, but it can sometimes happen after this time. It usually happens a few weeks after your transplant when your new bone marrow  begins to make blood cells . This is called engraftment.

Acute GvHD commonly affects the skin, digestive system and liver . However, it can affect other parts of the body.

Acute GvHD of the skin often starts with a rash on:

• the palms of your hands
• the soles of your feet
• your ears
• your face
• your shoulders
• the back of your neck

The rash may be itchy or painful.

Acute GvHD of your digestive system can cause:

• diarrhoea
• feeling or being sick
• loss of appetite and weight loss 
• tummy (abdominal) cramps or pain
• indigestion

Acute liver GvHD can cause changes to liver that are picked up on blood tests. Depending on how seriously the liver is affected, some people may get symptoms such as:

• yellowing of the skin and whites of the eyes (jaundice)
• a swollen liver that can be painful
• dark coloured pee
• pale coloured poo
• itching all over
• feeling sick

Chronic GvHD

Chronic GvHD generally starts from 100 days after your transplant. But it is possible for it to start earlier. You are more likely to get it if you have had acute GvHD. But it can happen even if you haven't. How seriously you had acute GvHD also affects your risk of developing chronic GvHD.

For some people, chronic GvHD can go on for several months or even years.

Chronic GvHD can affect any organ, the skin being the most common. Other common areas of the body affected include the:

• gut
• liver 
• mouth
• eyes
• lungs
• genitals such as the penis, vulva or vagina
• joints

Persistent, recurrent or late acute GvHD and overlap syndrome

Persistent, recurrent or late acute GvHD starts at least 100 days after your transplant. But you also have symptoms of acute GvHD.

Overlap syndrome has symptoms of both acute and chronic GvHD.

Grading acute GvHD

Your doctor assesses your GvHD and gives it a grade. There are 5 grades which range from grade 0 to grade 5. 

The grade depends on:

• the number of organs affected (skin, bowel, or liver) - GvHD can affect any or all of these organs
• how severe the GvHD is

Your treatment depends on the grade of your GvHD. You might not need any treatment if you have grade 1 GvHD, but you will need some type of treatment for grade 2 or above.

Grade 0

This means you have no GvHD.

Grade 1 

This is mild GvHD. It means up to a half (up to 50%) of your skin is affected.

Your liver and digestive system are not affected.

Grade 2 

This is moderate GvHD and means you have one or more of the following:

• more than a half of your skin (more than 50%) is affected
• you have mild changes to your liver
• have 3 to 4 episodes of diarrhoea a day
• constantly feel sick, are sick or have lost your appetite

Grade 3

This is severe GvHD.

You have liver changes with or without diarrhoea more than 5 times a day. Your skin may or may not be affected and you may be sick or have lost your appetite.

Grade 4 

This is very severe GvHD. You may be sick or have lost your appetite.

You also have one or more of the following:

• more than half (more than 50%) of your skin is affected. You might have blisters and peeling of the skin in some places
• your liver is affected and causing symptoms such as the whites of your eyes and skin to turn yellow (jaundice). Because your liver is not working properly you have severe diarrhoea
• you have severe tummy pain
• a lot of blood in your poo
• your bowel stops working properly. This is known as an ileus and symptoms include feeling full, tummy cramps, constipation, bloating, and feeling or being sick
• diarrhoea that can vary in frequency

Grading chronic GvHD

Your doctor assesses your GvHD. They look at the number of organs involved and how severe it is. Depending on this they give it one of the following grades: 

• mild
• moderate
• severe

Treatment for GvHD

The aim of treatment is to treat the GvHD and relieve symptoms.

Treatment works by lowering your body’s immune response and lower the number of T cells . The most common treatment for both acute and chronic GvHD is steroids .

You might have other treatments. Some treatments depend on which part of your body is affected.