Acute graft-versus-host disease: differing risk with differing graft sources and conditioning intensity

Acute graft-versus-host disease (aGVHD) is a constant component of allogeneic hematopoietic cell transplantation (HCT), with variations in incidence and severity affected by the graft source, human leukocyte antigen (HLA) compatibility, and the preparative regimen. The graft source – related versus unrelated donors, bone marrow (BM) versus peripheral blood (PB), umbilical cord blood (UCB) versus unrelated donor BM – are discussed in this review, as well as myeloablative versus reduced-intensity (RI) preparative regimens. Recent comparisons of matched related versus matched unrelated donor HCT support a minimal difference in aGVHD between these two donor sources. The use of BM versus mobilized PB in the matched related donor (MRD) setting has been compared in randomized as well as phase-II comparative clinical trials which support a slight increase in aGVHD in the adult population. Similar results have been seen in the unrelated donor (URD) setting, although based on minimal comparative data to date. Preliminary comparisons of UCB versus URD BM have shown a decreased incidence of aGVHD with UCB, despite increased HLA mismatching. Haploidentical HCT has continued to be explored, with limitations due to delayed immune reconstitution and disease relapse. Many reduced-intensity preparative regimens have been published, with a reduced or minimal difference in incidence of aGVHD when historically compared to myleoablative preparative regimens. More formal comparisons of the different graft sources as well as preparative regimen intensities will be required to determine a more accurate picture of the differences between these transplantation alternatives.