Choosing a regimen for prophylaxis of graft-versus-host disease

Graft-versus-host disease (GVHD), both acute and chronic, continues to be a majorproblem after allogeneic haemopoietic stem cell transplantation. Combinations ofpharmacological agents, such as methotrexate and cyclosporin, are most effective in patientstransplanted from human leucocyte antigen (HLA)-identical related donors, but less so inpatients transplanted from HLA-nonidentical or unrelated (;alternative') donors. Additionalagents such as tacrolimus and rapamycin are currently being tested. The approach to T celldepletion still requires further definition, especially in regard to the prevention of leukaemicrelapse. The addback of donor cells with some delay post-transplant may offer an intriguingalternative to intensified conditioning regimens for the prevention of leukaemic recurrencewithout necessarily increasing the risk of GVHD. All patients transplanted should be enteredinto well-designed studies in order to accrue data and advance our knowledge at the fastestrate possible.