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HLA-identical siblings versus haploidentical donors: full match still beats half match

Bone Marrow Transplantation volume 51, pages 344–345 (2016)Cite this article

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The resurgence of haploidentical donor transplantation over the past decade is a major advance in the field of hematopoietic cell transplantation (HCT). Several platforms have been described, such as ex vivo T-cell depletion techniques with positive-CD34+ selection, ‘mega-dose’ of purified CD34+ cells, or selective depletion of T-cells, and T-cell replete approaches that include use of intensified immune suppression or post-transplant high-dose cyclophosphamide.1, 2, 3 It is safe to say that haploidentical transplantation has become a well-accepted alternative donor source, with several studies reporting survival comparable to umbilical cord blood and matched unrelated donors.4, 5, 6, 7, 8 Ongoing clinical trials such as the BMT CTN 1101 (double cord versus haplo) will further clarify where haploidentical donors factor into the donor selection process.

Yan et al.,9 in this issue of Bone Marrow Transplantation, present their experience with T-cell replete haploidentical transplantation using intensified GvHD prophylaxis and compare the incidence and causes of mortality with HLA-identical sibling donor HCT recipients. Both groups received myeloablative conditioning. In their large cohort of 1411 patients, they show that the cumulative incidence of overall mortality and transplant-related mortality (TRM) was higher after haploidentical HCT, but there was no difference in the incidence of relapse-related mortality. TRM in haploidentical HCT recipients was primarily driven by a higher risk of infection-related mortality that mainly occurred in the first 3–6 months posttransplant. This is not surprising, given that the haploidentical donor cohort received more intensive immune suppression, including anti-thymocyte globulin. Intensifying pharmacologic GvHD prophylaxis and use of in vivo T-cell depletion is associated with slow and prolonged T-cell recovery, delay in immune reconstitution and its associated risks of infections.1, 10 Indeed, the authors have previously reported a higher incidence of invasive fungal disease, EBV reactivation and post-transplant lymphoproliferative disease, and CMV disease in haploidentical transplant recipients.11, 12 Previous studies from their group have also demonstrated a higher incidence of grade 1–4 acute GvHD in haploidentical HCT recipients, which would have resulted in more patients receiving post-transplant immune suppression compared with HLA-identical sibling donor recipients. However, mortality rates due to GvHD were low in both cohorts. Relapse was the most common cause of death in HLA-identical sibling donor HCT recipients and was second most common cause after infections in haploidentical donor transplant recipients. In subgroup analyses, they showed no difference in overall mortality or TRM in acute leukemia patients by donor source, but reported a higher incidence of both outcomes in patients with myelodysplastic syndromes who received haploidentical transplantation. The authors attribute this finding to longer duration of neutropenia in patients with myelodysplastic syndromes, although it is not clear why these two donor sources would have any differences in neutrophil engraftment and the number of patients with this particular disease was small.

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Authors and Affiliations

  1. Blood & Marrow Transplant Program, Cleveland Clinic, Cleveland, OH, USA

    R Hanna & N S Majhail

  2. Department of Pediatric Hematology, Oncology and Blood and Marrow Transplantation, Cleveland Clinic Children’s, Cleveland, OH, USA

    R Hanna

  3. Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA

    N S Majhail

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Correspondence to N S Majhail.

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Hanna, R., Majhail, N. HLA-identical siblings versus haploidentical donors: full match still beats half match. Bone Marrow Transplant 51, 344–345 (2016). https://doi.org/10.1038/bmt.2015.291

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