Your doctor will reduce your risk of developing GVHD by getting the best possible donor match for your transplant. And there are also some treatments to help prevent GVHD.
Getting the best donor match
GVHD can develop when the donor and the person receiving donor cells have a different tissue type. So your transplant specialist will make sure your donor is as closely matched to you as possible. This helps reduce your risk of GVHD. This is called tissue typing.
The HLA (human leukocyte antigen) system describes the proteins found on your blood cells. Your doctors will aim to find a donor with the closest HLA match possible.
Doctors usually test for 5 pairs of major HLA antigens. This gives a total of 10 antigens. We inherit one half of the pair from each of our parents. When choosing a donor, doctors aim to match 10 out of 10 HLA proteins. But it may be possible to do a transplant if they don't all match.
Finding a donor
Because we inherit the proteins from our parents, your best chance of a match is with a relative. You have a 1 in 4 (25%) chance of an exact match if you have a brother or sister.Other members of family can be tested if you don’t have siblings or if they don’t match your tissue type. Parents especially may be a close enough match.
Your doctor will search for a bone marrow match on a register of the general population if no one in your family is a match. Registers are kept by the British Bone Marrow Registry (NHSBT) and the Anthony Nolan Trust. Another possibility is to look at cord blood registries. These contain blood taken from umbilical cords at births, which can be used as a source of stem cells.
Treatments to prevent GVHD
Before and after your transplant, your doctors will use treatments to reduce the chance of GVHD. These treatments destroy T cells.
About T cells
T cells are white blood cells that are part of the immune system. They attack cells that are foreign to the body. GVHD happens when T cells in the donated bone marrow or stem cells (the graft) attack your own body cells (the host).
So reducing the number of T cells in the donor marrow or stem cells (the graft) reduces GVHD.
But sometimes GVHD is a good thing. The T cells in the graft will also attack any remaining cancer cells. This reduce the risk of your disease coming back. This is called the graft versus disease effect. Doctors try to strike a balance between preventing severe GVHD and getting some possible benefits from mild GVHD.
To lower your risk of GVHD you might have:
- treatment before your transplant
- treatment to remove T cells from the bone marrow or stem cells
- treatment after your transplant
Treatment before your transplant
Before your transplant you have a drug to reduce the number of T cells in your donated marrow or stem cells. You usually have a drug called ciclosporin (also called Deximune, Neoral or Sandimmum).
You start having it by drip (intravenously) a couple of days before your transplant. Before you go home you start taking it daily as a capsule - you should never take it with grapefruit or grapefruit juice because this can change the way the drug works.
You usually keep taking ciclosporin for about 6 months after the transplant.
As an alternative to ciclosporin, you might take a combination of mycophenolate mofetil (MMF) and tacrolimus.
You might have treatment with other drugs before your transplant. This could be:
- alemtuzumab (Campath)
- antithymocytic globulin (ATG)
- newer drugs, including tacrolimus or sirolimus (Rapamide)
Removing T cells from the bone marrow or stem cells
Your doctors can remove T cells from your donor’s bone marrow after it has been donated, or during the donation of stem cells. These methods are not commonly used. This is called T cell depletion.
Treatment after transplant
You have treatment with drugs after your transplant to reduce the risk of GVHD.
You might have some low doses of the chemotherapy drug methotrexate to suppress your immune system. This helps to keep the T cells down and so stops them attacking your body cells.
In some cases, you may have a chemotherapy drug called cyclophosphamide after a stem cell transplant. This is more likely after a half matched transplant from a family member, usually a parent or child. This is called a haploidentical transplant. The donor is a 50% match with the person having the transplant.
Before the transplant, you have chemotherapy to lower your immune system. These are usually lower doses of chemotherapy than in a traditional stem cell transplant. This is called reduced intensity conditioning.
A few days after the transplant, you have a high dose of cyclophosphamide. The donor's immune cells recognise your body cells as foreign, and start to multiply to attack them. The cyclophosphamide kills these rapidly growing immune cells, and so stops them attacking your body cells. This reduces side effects such as GVHD. You may have this treatment as part of a clinical trial.