ABO Mismatch in Allogeneic Hematopoietic Stem Cell Transplant: Effect on Short- and Long-term Outcomes

Background. The impact of ABO incompatibility (ABO-1) on hematopoietic stem cell transplant outcomes is still debated. Methods. We retrospectively investigated 432 consecutive transplants performed at our center (2012-2020). All patients but 6 were affected by hematologic malignancies. The effect of different ABO match combinations on engraftment rate, transfusion support, acute and chronic graft-versus-host disease incidences, nonrelapse mortality (NRM), disease-free survival, and overall survival was assessed in univariate and multivariate analysis. Significance was set at P< 0.05. Results. ABO match distribution among transplants was as follows: 223 ABO-compatible, 94 major ABO-1, 82 minor ABO-1, and 33 bidirectional ABO-1. At univariate analysis, major ABO-1 delayed the engraftment of neutrophils, platelets, and erythroid cells. At multivariate analysis, major ABO-1 transplants displayed delayed erythroid engraftment (odds ratio [OR], 0.51; 95% confidence intervals [CIs], 0.38-0.70; P< 0.0001) and hindered transfusion independence for both red blood cells (OR, 0.52; 95% CI, 0.37-0.72; P=0.0001) and platelets (0.60; 95% CI, 0.45-0.86; P=0.0048). Moreover, major ABO-1 transplants received greater amounts of blood products (P<0.0001 for red blood cells and P=0.0447 for platelets). In comparison with other ABO matches, major ABO-1 was associated with an increased NRM (OR, 1.67; 95% CI, 1.01-2.75; P=0.0427). No effects of ABO-mismatch were found on graft-versus-host disease, disease-free survival, and overall survival. Conclusions. Major ABO mismatch delays multilineage engraftment hinders transfusion independence and increases NRM. The prognostic impact of transfusion burden in hematopoietic stem cell transplantation deserves to be explored.