IntroductionHematopoietic stem cell transplantation (HSCT) remains the only curative therapy for many high-risk malignant hematologic diseases, as well as numerous life-threatening genetic and hematologic disorders. However, despite peritransplant prophylaxis, HSCT is frequently complicated by GVHD, which leads to significant morbidity and mortality. The risk of GVHD limits the broader application of HSCT where it has the potential to cure autoimmune diseases, facilitate transplant tolerance, and correct immunologic deficiencies, including HIV infection. 1 Conventional immunosuppressants remain the mainstay of treatment for GVHD, yet they frequently fail and carry a significant risk for infection. 2,3 It is therefore of significant interest to identify new, effective, and safe prophylactic and therapeutic approaches, particularly those that maintain the critical graft-versus-leukemia (GVL) effect of HSCT. In this review, we consider advances that have been made in understanding the role of dendritic cells (DCs) in GVHD and address the challenge of monitoring, targeting, and exploiting these cells to improve therapeutic outcomes.Our understanding of the pathogenesis of GVHD has advanced significantly over the past 45 years, since Billingham proposed that GVHD is the result of immunocompetent donor cells recognizing recipient antigens (Ags) in an immunocompromised host unable to reject donor cells. 4 The principal immunocompetent donor effector cells are T cells, and the vigor of the immune response is driven by differences in MHC and minor histocompatibility antigens (miHA). Furthermore, the crucial role of Ag-presenting cells (APCs), in particular uniquely well-equipped donor and recipient DCs, has begun to be elucidated, not only in GVHD, but also in the GVL effect of HSCT.
DC hematopoiesis and immunobiologyDCs are rare, heterogeneous bone marrow (BM)-derived professional APCs, first characterized in mouse spleen by Steinman and Cohn,5 that are distributed ubiquitously in blood, lymphoid, and peripheral tissues, especially at portals of entry. They arise from hematopoietic stem cells through specialized progenitor subsets 6 and are important in innate and adaptive immune function and in determining the balance between immunity and tolerance. In the normal steady state, DCs reside in "immature" or "semimature" states in the periphery where they constantly take up and process self-Ags and maintain self-tolerance. 7 Immunostimulatory DCs have undergone maturation after recognition of exogenous and endogenous alarmins/danger signals by Toll-like receptors (TLRs). 8 These signals include pathogen-associated molecular patterns in the form of microbial products and danger-associated molecular patterns, such as products of damaged or dying cells (eg, highmobility group protein B1 or DNA). DCs are also matured by CD40 ligation and by proinflammatory cytokines that can induce DC maturation ex vivo, independent of CD40 ligation. Maturation is associated with up-regulation of cell surface MHC gene products, costimulatory ...