Advances in Cell Therapy for Chronic Graft-versus-Host Disease: Prophylactic and Therapeutic Perspectives

Chronic graft-versus-host disease (cGvHD) can affect about 70% of people who undergo allogeneic hematopoietic stem cell transplantation (allo-HSCT). This condition is characterized by a complex immune dysregulation that leads to persistent inflammation and fibrosis. These complications can lead to long-term health issues that significantly affect the quality of life after HSCT. Conventional therapies such as corticosteroids and broad immunosuppressants are partially effective and have significant toxicity. They also fail to reverse established fibrotic damage. Advances in targeted pharmacological agents, including Bruton's tyrosine kinase inhibitors and JAK inhibitors, show improved outcomes for steroid-refractory cGvHD. However, their high costs and variable responses highlight the unmet need for more effective approaches. Cell-based therapies have emerged as promising strategies to modulate pathogenic immune responses and prevent or even treat cGvHD. Mesenchymal stromal cells (MSCs), regulatory T cells (Tregs), natural killer (NK) cells, and chimeric antigen receptor (CAR) T cells are being investigated for their immunoregulatory potential in preclinical and clinical trials, and they are considered a safer, more effective, and targeted approach to managing cGvHD. MSC-derived cytokines and exosomes can suppress Th17 cells and promote the generation of IL-10-expressing Tregs. This dual action helps reduce inflammation and tissue fibrosis associated with the cGvHD. Tregs and NK cells also help rebalance immune responses and suppress alloreactivity through different mechanisms. This review highlights underlying mechanisms, clinical efficacy, and challenges in translating these therapies into routine clinical practice. Additionally, it suggests that future trials should incorporate patient stratification based on cGvHD phases and phase-relevant biomarkers for managing disease progression more precisely.