Management of adult patients older than 40 years refractory to at least one immunosuppressive course: HLA-identical sibling HSCT using fludarabine-based conditioning

Allogeneic hematopoietic SCT (HSCT) from an HLA-identical sibling donor is the recommended upfront therapeutic option for young patients with SAA. The outcome of allogeneic sibling HSCT has remarkably improved during the last decade as a function of improvement in transplantation supportive care. However, there is still much debate concerning the upper age limit for sibling HSCT in SAA, particularly in patients who are refractory to at least one immunosuppressive course. Recent studies suggest that fludarabine-based conditioning may improve HSCT outcome in older patients with SAA. This review discusses available data about the use of fludarabine-based conditioning in transplantation of older patients with SAA. More definitive conclusions are needed from larger studies before the wide adoption of fludarabine-based conditioning as an alternative to the standard CY and ATG-based conditioning.