Prevention and management of graft-versus-host disease. Practical recommendations.

Graft-versus-host disease (GVHD) is the leading cause of failure of allogeneic bone marrow transplantation. The disease typically involves the skin, liver and gastrointestinal tract, with death frequently resulting from infectious complications. Cyclosporin-based drug combinations are the mainstay of GVHD prophylaxis. The major toxicity of cyclosporin is renal dysfunction, and optimal strategies of therapeutic drug monitoring to minimise toxicity and maximise clinical efficacy have yet to be devised. Initial treatment of established GVHD usually includes high dose corticosteroids. Patients failing to respond to first line therapy have a poor prognosis. Investigational approaches to decreasing the mortality associated with GVHD include using monoclonal antibodies directed at specific T cell subsets, and T cell depletion of bone marrow grafts.