American Society for Transplantation and Cellular Therapy & Cell Therapy Transplant Canada

Five Things Physicians and Patients Should Question

Released January 30, 2018; Last reviewed 2019

  1. 1

    Don’t routinely use peripheral blood stem cells for patients with aplastic anemia when a suitable bone marrow donor is available due to a higher risk of graft-versus-host disease.

    While faster engraftment with filgrastim-mobilized peripheral blood stem cells results in quicker recovery of peripheral blood counts compared to bone marrow in patients with aplastic anemia, the higher rate of graft-versus-host disease may be detrimental.

  2. 2

    Don’t use greater than 2 mg/kg/day of methylprednisolone (or equivalent) for the initial treatment of graft-versus-host disease.

    Published studies have shown no advantage to using methylprednisolone-equivalent doses higher than 2 mg/kg/day in acute graft-versus-host disease. In addition, using higher doses increases risks of corticosteroid related toxicity. Furthermore, at least in patients with grade I-II acute graft-versus-host disease, initial therapy with lower-dose corticosteroids at 1 mg/kg/day may be equivalent.

  3. 3

    Don’t routinely use two cord blood units for standard umbilical cord blood transplantation when a single unit of adequate size is available, recognizing that higher cell doses are preferred when using units with greater HLA mismatch.

    Randomized trials demonstrate similar clinical outcomes after single-unit and double-unit umbilical cord blood transplantation, including comparable rates of relapse, engraftment failure, overall survival, and transplantation related mortality. Moreover, graft-versus-host disease may be more frequent after double-cord blood transplantation.

  4. 4

    Don’t routinely use peripheral blood stem cells for matched unrelated donor transplantation using myeloablative conditioning and standard graft-versus-host disease prevention regimens when a suitable bone marrow donor is available.

    Patients undergoing myeloablative matched unrelated donor hematopoietic cell transplantation with standard graft-versus-host disease prophylaxis (calcineurin inhibitor and methotrexate) with a peripheral blood stem cell graft experience more symptomatic chronic graft-versus-host disease than those receiving bone marrow, without affecting relapse rates or overall survival. Peripheral blood stem cells may be considered in cases with substantial recipient/donor size discrepancy, donor preference, and for malignant diseases with high risk for graft failure.

  5. 5

    Don’t routinely give immunoglobulin replacement to adult hematopoietic cell transplantation recipients in the absence of recurrent infections regardless of the IgG level.

    Meta-analyses of controlled trials conclude that immunoglobulin replacement offers no advantage for infection prevention and overall survival, and may predispose to a higher risk of hepatic sinusoidal obstruction syndrome and venous thromboembolism, and impair the efficacy of post-transplant vaccinations. There may be subsets of patients where prophylactic immunoglobulin replacement may be considered, such as in umbilical cord blood transplant recipients, in children undergoing transplantation for inherited or acquired disorders associated with B-cell deficiency, and in chronic graftversus- host disease patients with recurrent sino-pulmonary infections.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

About the American Society for Transplantation and Cellular Therapy

The American Society for Transplantation and Cellular Therapy (ASTCT) is an international professional membership association of physicians, investigators and other healthcare professionals involved in blood and marrow transplantation and novel cellular therapies. The ASTCT represents the interests of transplant clinicians and investigators and the patients they serve in eight broad areas: research, representation, clinical standards, regulation, communications, accreditation, reimbursement, and recruiting and training clinical personnel.

About Cell Therapy Transplant Canada

Cell Therapy Transplant Canada (CTTC) is a member-led, national, multidisciplinary organization providing leadership and promoting excellence in patient care, research and education in the field of blood and marrow transplantation in Canada.

How This List Was Created

The American Society for Transplantation and Cellular Therapy (ASTCT) and Cell Therapy Transplant Canada (CTTC) established a Choosing Wisely BMT Task Force whose objective was to create a list of top five practices in blood and marrow transplantation to be questioned. The Task Force consisted of representatives from ASTCT’s Quality Outcomes, Education, and Practice Guidelines Committees, ASTCT’s Pharmacy Special Interest Group, CTTC Program Directors, and Center for International Blood and Marrow Transplant Research (CIBMTR). Suggestions for current transplantation practices to question were elicited from the CTTC Program Directors, members of ASTCT’s Quality Outcomes, Practice Guidelines and Education committees, and chairs of the CIBMTR scientific working committees. Suggestions were ranked based on their potential impact on harm reduction, cost reduction, necessity of the test or practice, and the strength of available evidence. Through a modified Delphi process, suggestions were narrowed down to six, which were then subjected to systematic reviews. After further discussion by the Task Force, the final five recommendations were generated.


  1. Killick SB, Bown N, Cavenagh J, et al. Guidelines for the diagnosis and management of adult aplastic anaemia. British journal of Haematology. 2016;172:187-207.

    Barone A, Lucarelli A, Onofrillo D, et al. Diagnosis and management of acquired aplastic anemia in childhood. Guidelines from the Marrow Failure Study Group of the Pediatric Haemato-Oncology Italian Association (AIEOP). Blood cells, Molecules & Diseases. 2015;55:40-47.

  2. Martin PJ, Rizzo JD, Wingard JR, et al. First- and second-line systemic treatment of acute graft-versus-host disease: recommendations of the American Society of Blood and Marrow Transplantation. Biology of Blood and Marrow Transplantation. 2012;18:1150-1163.

  3. Wagner JE, Jr., Eapen M, Carter S, et al. One-unit versus two-unit cord-blood transplantation for hematologic cancers. The New England Journal of Medicine. 2014;371:1685-1694.

    Hough R, Danby R, Russell N, et al. Recommendations for a standard UK approach to incorporating umbilical cord blood into clinical transplantation practice: an update on cord blood unit selection, donor selection algorithms and conditioning protocols. British Journal of Haematology. 2016;172:360-370.

  4. Anasetti C, Logan BR, Lee SJ, et al. Peripheral-blood stem cells versus bone marrow from unrelated donors. The New England Journal of Medicine. 2012;367:1487-1496.

    Lee SJ, Logan B, Westervelt P, et al. Comparison of Patient-Reported Outcomes in 5-Year Survivors Who Received Bone Marrow vs Peripheral Blood Unrelated Donor Transplantation: Long-term Follow-up of a Randomized Clinical Trial. JAMA Oncology. 2016;2:1583-1589.

  5. Tomblyn M, Chiller T, Einsele H, et al. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biology of Blood and Marrow Transplantation. 2009;15:1143-1238.

    Raanani P, Gafter-Gvili A, Paul M, Ben-Bassat I, Leibovici L, Shpilberg O. Immunoglobulin prophylaxis in hematopoietic stem cell transplantation: systematic review and meta-analysis. Journal of Clinical Oncology. 2009;27:770-781.