Throughout the 1980s, transplantation of unmodified (T cell-replete) bone marrow from full haplotype incompatible family donors was associated with an unsuccessful outcome because of graft failure and severe graft-versus-host disease (GVHD), at times affecting up to 90% of recipients. Although extensive T cell depletion of donor bone marrow was successful in preventing GVHD in children with severe combined immunodeficiency disease (SCID), results were disappointing in leukemic patients because the benefit of preventing GVHD was offset by graft failure. Resistance to engraftment appears to be mediated by host-derived cytotoxic T-lymphocyte precursors that survive supralethal conditioning. In the present paper, we review data that show that these genetic histocompatibility barriers can be overcome in stringent mouse models, employing lethally as well as sublethally irradiated recipients, by two major approaches that are synergistic to each other: escalation of hematopoietic progenitor cell dose and the use of nonalloreactive T cells. The former approach is already being successfully implemented in the treatment of leukemic patients.
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