Incidence and Risk Factors for Graft Failure after Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Myelofibrosis

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We investigated the incidence, risk factors, and prognosis for GF after allo-HSCT for MF. 211 Patients with MF who underwent allo-HSCT across 32 hematology centers in China between December 2008 and December 2024 were retrospectively analyzed. Among them, 66 underwent matched sibling donor HSCT, 127 haploidentical HSCT, and 18 unrelated donor HSCT. The overall GF incidence was 12.5%. GF incidence was significantly associated with donor type (matched sibling, 4.8%; alternative, 13.3%; P = 0.024). Pretransplant massive splenomegaly increased GF incidence (no splenomegaly, 8.3%; mild, 10%; massive, 18.5%; P = 0.19). In multivariate analysis, splenomegaly (HR = 8.627; P = 0.041) and alternative donors (HR = 3.529; P = 0.042) increased GF risk. With median follow-up of 734 days, 3-year OS was 65.5%, DFS 60.8%, relapse rate 10.1%, NRM rate 27.8%. Multivariate analysis showed pretransplant splenomegaly reduced 3-year DFS (HR = 1.671; P = 0.025), and alternative donors reduced 3-year OS (HR = 2.033; P = 0.015). Allo-HSCT provides curative outcomes for MF patients. However, GF remains a significant challenge, particularly in haploidentical HSCT and those with massive pretransplant splenomegaly. Health sciences/Risk factors Health sciences/Medical research graft failure myelofibrosis hematopoietic stem cell transplantation Figures Figure 1 Figure 2 Introduction Myelofibrosis (MF) is a kind of Philadelphia chromosome-negative myeloproliferative neoplasm characterized by bone marrow fibrosis, anemia, extramedullary hematopoiesis, splenomegaly, and constitutional symptoms [1] [2] . It includes primary MF and secondary MF arising from polycythemia vera or essential thrombocythemia. The prognosis of patients with MF is unfavorable [3] , with a heightened risk of transformation to acute myeloid leukemia and a median survival of approximately 6 years [4] . Despite the advent of JAK inhibitors, allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative treatment for MF. The 3-year overall survival (OS) is approximately 37–75% post-HSCT [5–8] , and data from the Center for International Blood and Marrow Transplant Research registry indicate a consistent upward trend in HSCT utilization for MF over the past decade [9] . However, the application of HSCT for MF is hampered by significant transplant-related complications. Graft failure(GF), which is defined as either lack of initial engraftment of donor cells (primary GF) or loss of donor cells after initial engraftment (secondary GF), is one of the most severe complication of allo-HSCT [10–13] . However, there is limited research focusing on GF in patients with MF, with particularly scarce data on haploidentical (Haplo)-HSCT. Further studies are required to explore the incidence, risk factors, and outcomes of GF after allo-HSCT. Therefore, we aimed to address this critical question through a multicenter retrospective study in China. Methods Patients This retrospective study included patients with MF who underwent allo-HSCT across 32 hematology centers in China between December 2008 and December 2024. MF was diagnosed according to the 2016 World Health Organization (WHO) diagnostic criteria. The final follow-up was conducted on December 31, 2024. This was a retrospective study; therefore, there were no additional interventions for the patients. This study was approved by the Ethics Committee of Peking University People's Hospital, which waived the need for informed consent. Definition The time to neutrophil engraftment was defined as the first of 3 consecutive days with an absolute neutrophil count (ANC) > 0.5 × 10 9 /L. The time to platelet engraftment was defined as the first of 7 consecutive days with a platelet count > 20 × 10 9 /L without transfusion support. Primary GF was defined as an ANC < 0.5 × 10 9 /L by day + 28 following stem cell infusion, hemoglobin level < 80 g/L, and platelet count < 20 × 10 9 /L. Secondary GF was defined according to the European Society for Blood and Marrow Transplantation (EBMT) criteria as the presence of an ANC < 0.5 × 10 9 /L occurring after initial engraftment and not related to relapse, infection, or drug toxicity. Acute graft-versus-host disease (GVHD) was graded according to the modified criteria based on the schema of the Mount Sinai Acute GVHD International Consortium. Chronic GVHD was graded according to the National Institutes of Health Chronic Graft-versus‐Host Disease Consensus Criteria. Splenomegaly was categorized as no, mild (splenomegaly no more than 15 cm on palpation or 22 cm of longitudinal diameter according to ultrasound scan evaluation), and massive (splenomegaly exceeding 15 cm on palpation or 22 cm of longitudinal diameter according to ultrasound scan evaluation). Relapse was defined as the reappearance of host cells and the morphological criteria for MF after remission [14] . Non-relapse mortality (NRM) was defined as death without relapse. Statistical analysis The probabilities of GF, GVHD, NRM, and relapse were estimated based on the cumulative incidence curves using the model. Competing risk regression analysis was used to identify the factors associated with GF. The probabilities of OS and disease-free survival (DFS) were estimated using the Kaplan–Meier method. The groups were compared using the Wilcoxon test. The adjusted probability of OS was estimated using the Cox proportional hazards model, considering other significant clinical variables in the final multivariate models. All variables that were significant (P < 0.10) in the univariate analysis were included in the multivariate stepwise analysis. All tests were two-sided, and P < 0.05 was considered significant. Data were analyzed using SPSS (version 27.0; IBM Corp., Armonk, NY); R (version 2.6.2; The R Foundation for Statistical Computing, Vienna, Austria). Results Patient cohort and transplantation details We evaluated 211 patients with MF who had undergone HSCT. The cohort included 145 (68.7%) patients diagnosed with primary MF, 20 (9.5%) with post-essential thrombocythemia or polycythemia vera MF, and 46 (21.8%) with MF that transformed into acute myeloid leukemia. The HSCT donor sources were distributed as follows: 66 (31.7%) patients received grafts from human leukocyte antigen-matched sibling donors (MSDs), 127 (60.2%) from Haplo donors, and 18 (8.5%) from unrelated donors. The patient characteristics are summarized in Table 1 . Table 1 Characteristics of patients Characteristics Value Age, Median (Range) 51 (13–69) Sex Male, n (%) 124 (58.8) Female, n (%) 87 (41.2) Diagnosis PMF, n (%) 145 (68.7) Post-PV/ET MF, n (%) 20 (9.5) MF-AML, n (%) 46 (21.8) Risk (DIPSS-plus) Int-1 risk, n (%) 22 (10.4) Int-2 risk, n (%) 175 (82.9) High risk, n (%) 14 (6.7) MIPSS70 v2.0 Intermediate risk, n (%) 8 (3.8) High risk, n (%) 99 (46.9) Very high risk, n (%) 25 (11.8) Not available, n (%) 79 (37.5) Driver mutation JAK2, n (%) 70 (33.2) MPL, n (%) 3 (1.4) CALR, n (%) 28 (13.3) Triple negative, n (%) 31 (14.7) Unknown, n (%) 79 (37.5) Pretransplant spleen treatment Splenic irradiation, n (%) 14 (6.6) Splenectomy, n (%) 11 (5.2) Pretransplant splenomegaly No splenomegaly 25 (11.8) Mild splenomegaly 118 (55.9) Massive splenomegaly 68 (32.2) Donor Matched sibling donor, n (%) 66 (31.7) Matched unrelated donor, n (%) 18 (8.5) Haploidentical donor, n (%) 127 (60.2) Conditioning BU/CY-based, n (%) 115 (54.5) BU/FLU-based, n (%) 27 (12.8) TBI-based, n (%) 41 (19.4) Other 28 (13.3) Stem cell sources PB + BM, n (%) 59 (28.0) PB, n (%) 117 (55.4) PB + BM + CB, n (%) 18 (8.5) PB + CB, n (%) 15 (7.1) BM, n (%) 2 (1) GVHD prevention MTX + CNI ± MMF-based 77 (36.5) MTX + CNI ± MMF + ATG-based 132 (62.5) MTX + CNI ± MMF + PtCY-based 2 (1) DSA before transplantation Positive, n (%) 27 (12.8) Negative, n (%) 122 (57.8) Unknown, n (%) 62 (29.4) MNC, Median (Range) 5.89 (2.62–15.72)×10 8 /Kg CD34, Median (Range) 10.74 (0.67–23.64)×10 6 /Kg PMF, primary myelofibrosis; Post-PV/ET MF, polycythemia vera or essential thrombocythemia myelofibrosis; MF-AML, myelofibrosis that transformed into acute myeloid leukemia; DIPSS, Dynamic International Prognostic Scoring System; Int, intermediate; MIPSS, Mutation-Enhanced International Prognostic Score System; BU/CY, busulfan and cyclophosphamide; BU/FLU, busulfan and fludarabine; TBI, total body irradiation; PB, peripheral blood; BM, bone marrow; CB, cord blood; GVHD, graft-versus-host disease; MTX, methotrexate; CNI, calcineurin inhibitor; MMF, mycophenolate mofetil; ATG, anti-thymocyte globulin; PtCY, post-transplant cyclophosphamide; DSA, donor-specific antibodies; MNC, mononuclear cell Incidence and risk factors for GF The Neutrophil engraftment rate at 28 days was 95.2%, and the platelet engraftment rate at 100 days was 67.8%. GF was observed in 25 patients, including 19 with primary GF and 6 with secondary GF. The cumulative incidence of GF was 12.5%. The incidence of engraftment and GF by different groups are showed in Fig. 1 . In the univariate analysis, massive splenomegaly (P = 0.094), alternative donors (P = 0.028), and the Dynamic International Prognostic Scoring System (P = 0.068) were associated with GF. No significant associations were found with hemoglobin level (P = 0.175), platelet count (P = 0.300), MF grading (per WHO criteria) (P = 0.394), donor-specific antibodies (DSA) (P = 0.149), graft mononuclear cell (MNC) count (0.836), or CD34 + cell count (P = 0.101). In the multivariate analysis, massive splenomegaly (hazard ratio [HR] = 8.627; 95% confidence interval [CI], 1.093–68.068; P = 0.041) and alternative donor HSCT (HR = 3.529; 95% CI, 1.049–11.869; P = 0.042) were significantly associated with an elevated risk of GF. The risk factors in multivariate analysis are summarized in Table 2 . The cumulative incidence of GF was 4.8% in MSD recipients and 16% in alternative donor recipients (P = 0.024). The cumulative incidence of GF in terms of splenic size was 8.3% for no splenomegaly, 10.0% for mild splenomegaly, and 18.5% for massive splenomegaly (P = 0.19). Table 2 Multivariate analysis of graft failure Factor No. of events/ evaluable HR (95% CI) P-Value Donor source MSD 3/66 1 Alternative donor 22/145 3.004 (0.871–10.365) 0.042 Pretransplant splenomegaly No splenomegaly 1/25 1 Mild splenomegaly 10/117 2.703 (0.334–21.891) 0.351 Massive splenomegaly 14/69 6.933 (0.896–55.305) 0.041 DIPSS Int-1 risk 5/22 1 Int-2 risk 16/175 0.399 (0.145–1.095) 0.074 High risk 4/14 1.519 (0.391–5.896) 0.546 MSD, matched sibling donor; DIPSS, Dynamic International Prognostic Scoring System; Int, intermediate; HR, hazard ratio; CI, confidence interval The incidence of GF in Haplo recipients was 13.3%. In the Haplo setting, the univariate analysis showed that massive splenomegaly (P = 0.004) and pretransplant white blood cell count (P = 0.046) were associated with GF incidence. No significant associations were found with the pretransplant white blood cell count (P = 0.404), hemoglobin level (P = 0.275), platelet count (P = 0.580), Dynamic International Prognostic Scoring System (P = 0.693), MF grading (per WHO criteria) (P = 0.213), DSA (P = 0.300), graft MNC count (P = 0.683), or CD34 + cell count (P = 0.115). In the multivariate analysis, massive splenomegaly (HR = 4.163; 95% CI, 1.291–13.427; P = 0.017) was associated with an increased incidence of GF. Outcomes of patients with GF Among the 25 patients with GF, 6 underwent secondary HSCT. Of these, 4 (66.6%) achieved successful engraftment and remained alive at the last follow-up, while the other 2 died. Among the remaining 19 patients, 6 (31%) achieved hematopoietic recovery and survived. The overall survival rate of patients with GF was 40%. Other transplantation outcomes Acute GVHD (grades II–IV) and chronic GVHD (moderate to severe) occurred in 44% and 25% of patients, respectively. With a median follow-up duration of 734 days, the 3-year OS and DFS rates were 65.5% and 60.8%, respectively. The 3-year relapse rate was 10.1%, whereas the NRM rate was 27.8%. These transplantation outcomes are summarized in Table 3 and Fig. 2 . Table 3 Transplantation outcomes Group Outcomes OS (3 y) DFS (3 y) CIR (3 y) NRM (3 y) GF (1 y) Overall cohort 65.5% 60.8% 10.1% 27.8% 12.5 DIPSS-plus Int-1 risk 64% 54.6% 4.76% 21.4% 23.2% Int-2 risk 65.3% 59.6% 10.7% 28.5% 9.7% High risk 68.8% 59% 9.83% 31.2% 30.8% Donor type MSD 76% 63.4% 13.6% 14.5% 4.8% Alternative donor 60.3% 56.7% 8.27% 34.2% 13.3% Splenomegaly Normal 68.6% 65.9% 14.6% 22.3% 8.3% Mild 64.6% 55.8% 10.7% 22.1% 10% Massive 59.6% 49.3% 6.83% 40.6% 18.5% OS, overall survival; DFS, disease-free survival; CIR, cumulative incidence of relapse; NRM, non-relapse mortality; GF, graft failure; MSD, matched sibling donor; DIPSS, Dynamic International Prognostic Scoring System; Int, intermediate The univariate analysis revealed a significant association between OS and alternative donors (P = 0.011) and massive splenomegaly (P = 0.069). Massive splenomegaly (P = 0.016) and alternative donors (P = 0.059) were included in the multivariate analysis for DFS. Splenomegaly and donor type were not associated with the cumulative incidence of relapse. Pretransplant leukocyte count, hemoglobin level, platelet count, bone marrow fibrosis grade, DSA, graft MNC count, and CD34 + cell count were not significantly associated with OS, DFS, cumulative incidence of relapse, and NRM. In the multivariate analysis, massive splenomegaly was associated with reduced DFS (HR = 1.671; 95% CI, 1.065–2.623; P = 0.025). Alternative donors were associated with reduced OS (HR = 2.033; 95% CI, 1.145–3.611; P = 0.015). The DFS rates were 65.9% for patients without splenomegaly, 55.8% for those with mild splenomegaly, and 49.3% for those with massive splenomegaly (P = 0.037, log-rank test). The OS rates were 76% and 60.3% for MSD and alternative donor recipients, respectively (P = 0.009, log-rank test). The NRM rates were 22.3% for patients without splenomegaly, 22.1% for those with mild splenomegaly, 40.6% for those with massive splenomegaly (P = 0.030, competing risk test), 14.5% for MSD recipients, and 34.2% for alternative donor recipients (P = 0.002, competing risk test). Discussion Allo-HSCT is a potentially curative treatment for MF. In the current study, we demonstrated that GF remains a critical obstacle to allo-HSCT in patients with MF and that alternative donor type and pretransplant splenomegaly were associated with an increased risk of GF. In a previous report, the incidence of GF was 5–20% [15,16] and was associated with a 60% mortality rate. A recent EBMT study revealed a 5-year OS rate of only 14% in patients with GF [14] , underscoring the urgent need for strategies to prevent and mitigate engraftment failure. Pretransplant splenomegaly is a well-established prognostic factor that influences engraftment and transplant outcomes in patients with MF [17,18] . The mechanisms underlying the impact of splenomegaly on engraftment likely involve spleen-mediated destruction of hematopoietic cells, release of proinflammatory cytokines, and enhanced immune rejection [19] . These findings highlight the need for effective pretransplant spleen management. Current EBMT guidelines recommend JAK2 inhibitors, such as ruxolitinib, as first-line therapy for pretransplant splenomegaly, with approximately 50% of patients experiencing spleen size reduction, symptom alleviation, and improved prognosis [19,20] . Second-line treatment options for patients refractory to ruxolitinib include splenic irradiation or splenectomy [21,22] . In the largest retrospective study involving 1,195 patients, pretransplant splenectomy was associated with reduced NRM but an increased risk of relapse, with no overall impact on OS. However, in high-risk subgroups or patients with massive splenomegaly, splenectomy improved OS without affecting the relapse rates [22] . The optimal approach for pretransplant spleen management and post-treatment care requires further prospective investigation. Haplo donors have been suggested to be another important factor associated with GF [8,23,24,9] . In our cohort, both Haplo and unrelated donor transplants were associated with higher GF rates than MSD transplants. This observation is consistent with those of previous reports from both EBMT and Center for International Blood and Marrow Transplant Research. An elevated incidence of GF, up to 20% in Haplo transplant settings, was observed in patients with MF, contributing to considerable NRM [7,25,26] . To reduce GF rates during Haplo-HSCT, proactive management of splenomegaly, optimization of conditioning regimens, and robust prophylaxis for GVHD and infections are essential. To date, there have been few reports on Haplo-HSCT for MF. Therefore, improving the outcomes of Haplo-HSCT in patients with MF is necessary. Other factors previously associated with GF, including DSAs, CD34 + cell dose, female donors, and elevated pretransplant ferritin levels, were not significantly correlated with GF in our study [27–29,11] . This lack of association may be attributed to our limited sample size, low GF event rate, or missing data, warranting further investigation in larger cohorts. In previous reports, GF was associated with a high mortality rate [15,16] . Therapeutic options for GF are limited and often result in poor outcomes. Immunosuppressive agents and hematopoietic growth factors (e.g., granulocyte colony-stimulating factor or thrombopoietin receptor agonists) are largely ineffective and result in high mortality rates [30,31] . Emerging evidence supports second transplantation and CD34 boost cell infusion as viable salvage strategies [15] . Further prospective studies are required to validate these findings. This study has several limitations. First, this was a retrospective study with a small sample size. Second, the time span was very wide; therefore, heterogeneity might have led to bias in the study. Overall, this study describes the current status of allo-HSCT for MF in China. In conclusion, allo-HSCT provides curative outcomes for patients with MF. However, GF remains a significant challenge in allo-HSCT, particularly in Haplo-HSCT and those with massive pretransplant splenomegaly. This study suggests that management of splenomegaly may improve transplantation outcomes. Declarations Acknowledgments This work was supported (in part) by the National Natural Science Foundation of China (Grant No. 8227010768), Beijing Natural Science Foundation (Grant No. 7252147), and Peking University Clinical Scientist Training Program (Grant No. BMU2025PYJH015). Disclosure statement All authors declare no conflict of interest. Data sharing and data availability The data that support the findings of this study are available from the corresponding author upon reasonable request. References Gangat N, Tefferi A. Myelofibrosis biology and contemporary management[J]. British Journal of Haematology, 2020, 191(2): 152-170. Garmezy B, Schaefer J K, Mercer J, et al. A provider’s guide to primary myelofibrosis: Pathophysiology, diagnosis, and management[J]. Blood Reviews, 2021, 45: 100691. Abdel-Wahab O I, Levine R L. Primary myelofibrosis: Update on definition, pathogenesis, and treatment[J]. Annual Review of Medicine, 2009, 60: 233-245. Tefferi A. Primary myelofibrosis: 2021 update on diagnosis, risk-stratification and management[J]. American Journal of Hematology, 2021, 96(1): 145-162. Ayyappan S, Janakiram M, Raghupathy R. Current and emerging therapies in primary myelofibrosis[J]. Cardiovascular & Hematological Disorders Drug Targets, 2012, 12(1): 6-20. Gambella M, Bregante S, Raiola A M, et al. Haploidentical hematopoietic cell transplantation for myelofibrosis in the ruxolitinib era[J]. Transplantation and Cellular Therapy, 2023, 29(1): 49.e1-49.e7. Bewersdorf J P, Sheth A H, Vetsa S, et al. Outcomes of allogeneic hematopoietic cell transplantation in patients with myelofibrosis—a systematic review and meta-analysis[J]. Transplantation and Cellular Therapy, 2021, 27(10): 873.e1-873.e13. Ghalehsari N, Castillo Tokumori F, Chen Z, et al. Transplant outcomes in myelofibrosis: Impact of donor type (cord blood grafts supported by CD34+ selected cells [haplo-cord] versus matched donors)[J]. Transplantation and Cellular Therapy, 2024, 30(11): 1100.e1-1100.e11. Jain T, Estrada-Merly N, Salas M Q, et al. Donor types and outcomes of transplantation in myelofibrosis: A CIBMTR study[J]. Blood Advances, 2024, 8(16): 4281-4293. Huang X J. Overcoming graft failure after haploidentical transplantation: Is this a possibility?[J]. Best Practice & Research Clinical Haematology, 2021, 34(1): 101255. Alchalby H, Yunus D R, Zabelina T, et al. Incidence and risk factors of poor graft function after allogeneic stem cell transplantation for myelofibrosis[J]. Bone Marrow Transplantation, 2016, 51(9): 1223-1227. Jungius S, Adam F C, Grosheintz K, et al. Characterization of engraftment dynamics in myelofibrosis after allogeneic hematopoietic cell transplantation including novel conditioning schemes[J]. Frontiers in Oncology, 2023, 13: 1205387. Gergis U, Kuriakose E, Shore T, et al. Allogeneic transplantation for patients with advanced myelofibrosis: Splenomegaly and high serum LDH are adverse risk factors for successful engraftment[J]. Clinical Lymphoma, Myeloma & Leukemia, 2016, 16(5): 297-303. McLornan D P, Hernandez-Boluda J C, Czerw T, et al. Allogeneic haematopoietic cell transplantation for myelofibrosis: Proposed definitions and management strategies for graft failure, poor graft function and relapse: best practice recommendations of the EBMT chronic malignancies working party[J]. Leukemia, 2021, 35(9): 2445-2459. Giammarco S, Raiola A M, Di Grazia C, et al. Second haploidentical stem cell transplantation for primary graft failure[J]. Bone Marrow Transplantation, 2021, 56(6): 1291-1296. Ozdemir Z N, Civriz Bozdağ S. Graft failure after allogeneic hematopoietic stem cell transplantation[J]. Transfusion and Apheresis Science, 2018, 57(2): 163-167. Polverelli N, Mauff K, Kröger N, et al. Impact of spleen size and splenectomy on outcomes of allogeneic hematopoietic cell transplantation for myelofibrosis: A retrospective analysis by the chronic malignancies working party on behalf of european society for blood and marrow transplantation (EBMT)[J]. American Journal of Hematology, 2021, 96(1): 69-79. Luther M, Henes F O, Zabelina T, et al. Spleen volume and length determined by computed tomography impact outcome after allogeneic stem cell transplantation for myelofibrosis[J]. Bone Marrow Transplantation, 2023, 58(7): 755-761. Gagelmann N, Bose P, Gupta V, et al. Consistency of spleen and symptom reduction regardless of cytopenia in patients with myelofibrosis treated with pacritinib[J]. Clinical Lymphoma, Myeloma & Leukemia, 2024, 24(11): 796-803. Lucijanic M, Krecak I, Soric E, et al. Palpable spleen size is differently prognostic in primary and secondary myelofibrosis[J]. Leukemia & Lymphoma, 2023, 64(4): 893-896. Gagelmann N, Hobbs G S, Campodonico E, et al. Splenic irradiation for myelofibrosis prior to hematopoietic cell transplantation: A global collaborative analysis[J]. American Journal of Hematology, 2024, 99(5): 844-853. Malato A, Rossi E, Tiribelli M, et al. Splenectomy in myelofibrosis: Indications, efficacy, and complications[J]. Clinical Lymphoma Myeloma and Leukemia, 2020, 20(9): 588-595. Jain T, Tsai H L, Elmariah H, et al. Haploidentical donor hematopoietic cell transplantation for myelodysplastic/myeloproliferative overlap neoplasms: Results from a north American collaboration[J]. Haematologica, 2023, 108(12): 3321-3332. Yoon J H, Min G J, Park S S, et al. HLA-mismatched donor and high ferritin level showed poor clinical outcomes after allogeneic hematopoietic cell transplantation in patients with advanced myelofibrosis[J]. Therapeutic Advances in Hematology, 2020, 11: 2040620720936935. Murata M, Takenaka K, Uchida N, et al. Comparison of outcomes of allogeneic transplantation for primary myelofibrosis among hematopoietic stem cell source groups[J]. Biology of Blood and Marrow Transplantation: Journal of the American Society for Blood and Marrow Transplantation, 2019, 25(8): 1536-1543. Markiewicz M, Dzierzak Mietla M, Wieczorkiewicz A, et al. Safety and outcome of allogeneic stem cell transplantation in myelofibrosis[J]. European Journal of Haematology, 2016, 96(3): 222-228. Hickey C L, Zhang M J, Allbee-Johnson M, et al. Donor type does not impact late graft failure following reduced-intensity allogeneic hematopoietic cell transplantation with post-transplant cyclophosphamide-based graft-versus-host disease prophylaxis[J]. Transplantation and Cellular Therapy, 2025, 31(3): 174.e1-174.e12. Lima A C M, Bonfim C, Getz J, et al. Untreated Donor-Specific HLA Antibodies Are Associated With Graft Failure and Poor Survival After Haploidentical Transplantation With Post-Transplantation Cyclophosphamide in Pediatric Patients With Nonmalignant Disorders[J]. Transplantation and Cellular Therapy, 2022, 28(10): 698.e1-698.e11. Xie Y, Parekh J, Tang Z, et al. Donor-specific antibodies and primary graft failure in allogeneic hematopoietic stem cell transplantation: A systematic review and meta-analysis[J]. Transplantation and Cellular Therapy, 2021, 27(8): 687.e1-687.e7. Ma R, Zhu D P, Zhang X H, et al. Salvage haploidentical transplantation for graft failure after first haploidentical allogeneic stem cell transplantation: An updated experience[J]. Bone Marrow Transplantation, 2024, 59(7): 991-996. Sun Y Q, Wang Y, Wang F R, et al. Graft failure in patients with hematological malignancies: A successful salvage with a second transplantation from a different haploidentical donor[J]. Frontiers in Medicine, 2021, 8: 604085. Additional Declarations The authors have declared there is NO conflict of interest to disclose. Cite Share Download PDF Status: Published Journal Publication published 25 Nov, 2025 Read the published version in Bone Marrow Transplantation → Version 1 posted Editorial decision: revise 06 Aug, 2025 Review # 2 received at journal 05 Aug, 2025 Reviewer # 2 agreed at journal 16 Jul, 2025 Review # 1 received at journal 11 Jul, 2025 Reviewer # 1 agreed at journal 03 Jul, 2025 Reviewers invited by journal 03 Jul, 2025 Submission checks completed at journal 03 Jul, 2025 First submitted to journal 02 Jul, 2025 Unknown event 30 Jun, 2025 Editor assigned by journal 29 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Sun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYPACCQYG9vaDj8FsZuYGIrXwnEk2ZmAwAGphJEoLSFeCmTRYCwMBLfIzco9J85RZyJvzHEirLqj4E83fDtTyo2IbTi0GN/LSpHnOSRjubG88dnvGGYPcGYcZGxh7ztzGrUUix0yat02CccOZA2m3edsMchuAWpgZ23BrkZ8B0WK/4UaCWTFIy3xCWhhuQLQkgrQwg7RsIKTF4MwbY8s55ySSN5w5kyzNc8Y4dyNQy0F8fpFvzzG88aasznbD8faDn3kq5HLnnT988MGPCjwOY2BgkWBgQxM6gE89EDB/wNAyCkbBKBgFowAZAABHI1fZsAw7jgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-1856-2231","institution":"Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease","correspondingAuthor":true,"prefix":"","firstName":"Yuqian","middleName":"","lastName":"Sun","suffix":""},{"id":480217520,"identity":"06d6b661-a45a-4754-9177-baf096b8ea01","order_by":1,"name":"Jun Zhu","email":"","orcid":"","institution":"Shanghai Zhaxin Hospital, Shanghai, China","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Zhu","suffix":""},{"id":480217521,"identity":"584f3d1e-a01f-495b-9d86-d5fc897f1321","order_by":2,"name":"Jia Chen","email":"","orcid":"","institution":"National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Jia","middleName":"","lastName":"Chen","suffix":""},{"id":480217522,"identity":"b227b0fc-2549-4f8b-8754-05f03799c8dd","order_by":3,"name":"Erlie Jiang","email":"","orcid":"https://orcid.org/0000-0003-0237-6063","institution":"State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology \u0026 Blood Diseases 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Army","correspondingAuthor":false,"prefix":"","firstName":"Fang","middleName":"","lastName":"Zhou","suffix":""},{"id":480217529,"identity":"9009e305-5c58-495a-9875-7e8e758867c1","order_by":10,"name":"Mingfeng Zhao","email":"","orcid":"https://orcid.org/0000-0002-5995-7558","institution":"Tianjin First Central Hospital;Nankai University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Mingfeng","middleName":"","lastName":"Zhao","suffix":""},{"id":480217530,"identity":"127a69ff-0163-4e21-9951-6e3ad412f51b","order_by":11,"name":"Jinsong Yan","email":"","orcid":"https://orcid.org/0000-0003-4109-2602","institution":"the Second Hospital of Dalian Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jinsong","middleName":"","lastName":"Yan","suffix":""},{"id":480217531,"identity":"d7d3b628-57dd-4270-b931-ed8891b6f886","order_by":12,"name":"Yehui Tan","email":"","orcid":"","institution":"The First Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Yehui","middleName":"","lastName":"Tan","suffix":""},{"id":480217532,"identity":"52f5ec11-7150-4d29-99ff-ab687311a5d5","order_by":13,"name":"Shuangnian Xu","email":"","orcid":"https://orcid.org/0000-0002-4041-9039","institution":"Southwest Hospital, Third Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shuangnian","middleName":"","lastName":"Xu","suffix":""},{"id":480217533,"identity":"c953b7e3-eebf-4cfc-adfb-60c889c0143c","order_by":14,"name":"Guanchen Bai","email":"","orcid":"","institution":"tai an shi zhong xin yi yuan Tai'an, Shandong","correspondingAuthor":false,"prefix":"","firstName":"Guanchen","middleName":"","lastName":"Bai","suffix":""},{"id":480217534,"identity":"e834542e-6261-4fe3-9e9e-b952e4f154f0","order_by":15,"name":"Weijie 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University","correspondingAuthor":false,"prefix":"","firstName":"Jian","middleName":"","lastName":"Zhou","suffix":""},{"id":480217538,"identity":"f18a3bcf-62c3-496f-81b8-5b83e68b6b57","order_by":19,"name":"Sanbin Wang","email":"","orcid":"https://orcid.org/0000-0002-4802-0292","institution":"920th Hospital of Joint Logistics Support Force of People's Liberation Army of China","correspondingAuthor":false,"prefix":"","firstName":"Sanbin","middleName":"","lastName":"Wang","suffix":""},{"id":480217539,"identity":"781ac24b-a4e1-4307-b4c3-990fb1b98d6b","order_by":20,"name":"Peng Zhao","email":"","orcid":"","institution":"Affiliated Hospital of Guizhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Peng","middleName":"","lastName":"Zhao","suffix":""},{"id":480217540,"identity":"b9beb7c6-f1e2-4678-b96c-58a66addf41c","order_by":21,"name":"Kourong Miao","email":"","orcid":"https://orcid.org/0000-0002-0266-9715","institution":"the First Affiliated Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Kourong","middleName":"","lastName":"Miao","suffix":""},{"id":480217541,"identity":"f45a6cc5-8260-4ee7-b4f5-1db820a67b0f","order_by":22,"name":"Ying Lu","email":"","orcid":"","institution":"Ningbo University Affiliated People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Lu","suffix":""},{"id":480217542,"identity":"be58d9d3-6ab9-4418-bcce-7f34878475f8","order_by":23,"name":"Li Ding","email":"","orcid":"https://orcid.org/0000-0001-9460-9201","institution":"the General Hospital of Air Force PLA","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Ding","suffix":""},{"id":480217543,"identity":"5fbc264b-8945-4a6c-988b-a2be0fc3eb28","order_by":24,"name":"Zhiling Yan","email":"","orcid":"https://orcid.org/0009-0007-7856-2651","institution":"Department of Hematology, The Affiliated Hospital of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhiling","middleName":"","lastName":"Yan","suffix":""},{"id":480217544,"identity":"297f410f-2b5f-4258-96c4-d68840d07018","order_by":25,"name":"Liping Dou","email":"","orcid":"https://orcid.org/0000-0001-7352-9560","institution":"the Fifth Medical Center of Chinese PLA General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Liping","middleName":"","lastName":"Dou","suffix":""},{"id":480217545,"identity":"201791a7-01d8-45b5-b088-ff1a05d3e366","order_by":26,"name":"Mei Lan","email":"","orcid":"","institution":"Guangxi Zhuang Autonomous Region People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mei","middleName":"","lastName":"Lan","suffix":""},{"id":480217546,"identity":"c86f67ec-706a-4180-9ef7-20d4fb499507","order_by":27,"name":"Shun-qing Wang","email":"","orcid":"","institution":"Guangzhou First People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shun-qing","middleName":"","lastName":"Wang","suffix":""},{"id":480217547,"identity":"9b7dad48-d67a-4c58-8e8e-ef35d69e89b8","order_by":28,"name":"Zhiguo Wang","email":"","orcid":"","institution":"Harbin Institute of Hematology and Oncology","correspondingAuthor":false,"prefix":"","firstName":"Zhiguo","middleName":"","lastName":"Wang","suffix":""},{"id":480217548,"identity":"1c3eac16-db93-4cb2-9067-f38afd766a30","order_by":29,"name":"Hai Yi","email":"","orcid":"https://orcid.org/0000-0003-3794-266X","institution":"General Hospital of Western Theater Command,","correspondingAuthor":false,"prefix":"","firstName":"Hai","middleName":"","lastName":"Yi","suffix":""},{"id":480217549,"identity":"20cfbe3c-ee9e-4f0e-801a-266ac00d0f66","order_by":30,"name":"Hai-Long Yuan","email":"","orcid":"","institution":"First Affiliated Hospital of Xinjiang Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hai-Long","middleName":"","lastName":"Yuan","suffix":""},{"id":480217550,"identity":"139448b9-f267-4600-b9be-5379949779ff","order_by":31,"name":"Xiaosheng Fang","email":"","orcid":"","institution":"Provincial Hospital Affiliated to Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Xiaosheng","middleName":"","lastName":"Fang","suffix":""},{"id":480217551,"identity":"6863d63f-74a0-4cf7-ab27-21f044533fde","order_by":32,"name":"Hao Zhang","email":"","orcid":"","institution":"Affiliated Hospital of Jining Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Zhang","suffix":""},{"id":480217552,"identity":"5a4261b2-47e7-4c34-95bb-9a93b499dabb","order_by":33,"name":"XiaoJun Huang","email":"","orcid":"https://orcid.org/0000-0002-2145-6643","institution":"Peking University People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"XiaoJun","middleName":"","lastName":"Huang","suffix":""}],"badges":[],"createdAt":"2025-06-29 14:50:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7003361/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7003361/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41409-025-02746-4","type":"published","date":"2025-11-25T05:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":86218384,"identity":"fc4df9b3-8648-4008-beca-bfcf0637d1e2","added_by":"auto","created_at":"2025-07-08 06:30:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":331215,"visible":true,"origin":"","legend":"\u003cp\u003eIncidence of graft failure and engraftment\u003c/p\u003e\n\u003cp\u003e(A) Incidence of GF based on pretransplant splenomegaly. (B) Incidence of GF based on donor type. (C) ANC engraftment based on pretransplant splenomegaly. (D) ANC engraftment based on donor type. (E) PLT engraftment based on pretransplant splenomegaly. (F) PLT engraftment based on donor type.\u003c/p\u003e\n\u003cp\u003eGF, graft failure; ANC, absolute neutrophil count; PLT, platelet; MSD, matched sibling donor\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7003361/v1/2a99cb4c03407ec7feba1d3a.png"},{"id":86217631,"identity":"88df76ad-e8d1-4fdb-ab61-ae2dca08547c","added_by":"auto","created_at":"2025-07-08 06:22:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":403240,"visible":true,"origin":"","legend":"\u003cp\u003eIncidence of overall survival, disease-free survival, relapse, and non-relapse mortality.\u003c/p\u003e\n\u003cp\u003e(A) Overall survival based on pretransplant splenomegaly. (B) Overall survival based on donor type. (C) Disease-free survival based on pretransplant splenomegaly. (D) Disease-free survival based on donor type. (E) Relapse based on pretransplant splenomegaly. (F) Relapse based on donor type. (G) Non-relapse mortality based on pretransplant splenomegaly. (H) Non-relapse mortality based on donor type.\u003c/p\u003e\n\u003cp\u003eMSD, matched sibling donor\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7003361/v1/2b55530b3d3c32fd507b363a.png"},{"id":96798734,"identity":"5c6a1f1e-12db-4f7e-b729-314ffbf67711","added_by":"auto","created_at":"2025-11-26 08:11:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1647110,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7003361/v1/b08d1c4b-227e-47f0-ad0d-d3e3febe0710.pdf"}],"financialInterests":"The authors have declared there is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"Incidence and Risk Factors for Graft Failure after Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Myelofibrosis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMyelofibrosis (MF) is a kind of Philadelphia chromosome-negative myeloproliferative neoplasm characterized by bone marrow fibrosis, anemia, extramedullary hematopoiesis, splenomegaly, and constitutional symptoms\u003csup\u003e[1] [2]\u003c/sup\u003e. It includes primary MF and secondary MF arising from polycythemia vera or essential thrombocythemia. The prognosis of patients with MF is unfavorable\u003csup\u003e[3]\u003c/sup\u003e, with a heightened risk of transformation to acute myeloid leukemia and a median survival of approximately 6 years\u003csup\u003e[4]\u003c/sup\u003e. Despite the advent of JAK inhibitors, allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative treatment for MF. The 3-year overall survival (OS) is approximately 37–75% post-HSCT\u003csup\u003e[5–8]\u003c/sup\u003e, and data from the Center for International Blood and Marrow Transplant Research registry indicate a consistent upward trend in HSCT utilization for MF over the past decade\u003csup\u003e[9]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHowever, the application of HSCT for MF is hampered by significant transplant-related complications. Graft failure(GF), which is defined as either lack of initial engraftment of donor cells (primary GF) or loss of donor cells after initial engraftment (secondary GF), is one of the most severe complication of allo-HSCT\u003csup\u003e[10–13]\u003c/sup\u003e. However, there is limited research focusing on GF in patients with MF, with particularly scarce data on haploidentical (Haplo)-HSCT. Further studies are required to explore the incidence, risk factors, and outcomes of GF after allo-HSCT. Therefore, we aimed to address this critical question through a multicenter retrospective study in China.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e \u003cb\u003ePatients\u003c/b\u003e \u003c/p\u003e\u003cp\u003eThis retrospective study included patients with MF who underwent allo-HSCT across 32 hematology centers in China between December 2008 and December 2024. MF was diagnosed according to the 2016 World Health Organization (WHO) diagnostic criteria. The final follow-up was conducted on December 31, 2024. This was a retrospective study; therefore, there were no additional interventions for the patients. This study was approved by the Ethics Committee of Peking University People's Hospital, which waived the need for informed consent.\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eDefinition\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eThe time to neutrophil engraftment was defined as the first of 3 consecutive days with an absolute neutrophil count (ANC) \u0026gt; 0.5 × 10\u003csup\u003e9\u003c/sup\u003e/L. The time to platelet engraftment was defined as the first of 7 consecutive days with a platelet count \u0026gt; 20 × 10\u003csup\u003e9\u003c/sup\u003e/L without transfusion support. Primary GF was defined as an ANC \u0026lt; 0.5 × 10\u003csup\u003e9\u003c/sup\u003e/L by day + 28 following stem cell infusion, hemoglobin level \u0026lt; 80 g/L, and platelet count \u0026lt; 20 × 10\u003csup\u003e9\u003c/sup\u003e/L. Secondary GF was defined according to the European Society for Blood and Marrow Transplantation (EBMT) criteria as the presence of an ANC \u0026lt; 0.5 × 10\u003csup\u003e9\u003c/sup\u003e/L occurring after initial engraftment and not related to relapse, infection, or drug toxicity. Acute graft-versus-host disease (GVHD) was graded according to the modified criteria based on the schema of the Mount Sinai Acute GVHD International Consortium. Chronic GVHD was graded according to the National Institutes of Health Chronic Graft-versus‐Host Disease Consensus Criteria.\u003c/p\u003e\u003cp\u003eSplenomegaly was categorized as no, mild (splenomegaly no more than 15 cm on palpation or 22 cm of longitudinal diameter according to ultrasound scan evaluation), and massive (splenomegaly exceeding 15 cm on palpation or 22 cm of longitudinal diameter according to ultrasound scan evaluation). Relapse was defined as the reappearance of host cells and the morphological criteria for MF after remission\u003csup\u003e[14]\u003c/sup\u003e. Non-relapse mortality (NRM) was defined as death without relapse.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe probabilities of GF, GVHD, NRM, and relapse were estimated based on the cumulative incidence curves using the model. Competing risk regression analysis was used to identify the factors associated with GF. The probabilities of OS and disease-free survival (DFS) were estimated using the Kaplan–Meier method. The groups were compared using the Wilcoxon test. The adjusted probability of OS was estimated using the Cox proportional hazards model, considering other significant clinical variables in the final multivariate models. All variables that were significant (P \u0026lt; 0.10) in the univariate analysis were included in the multivariate stepwise analysis. All tests were two-sided, and P \u0026lt; 0.05 was considered significant. Data were analyzed using SPSS (version 27.0; IBM Corp., Armonk, NY); R (version 2.6.2; The R Foundation for Statistical Computing, Vienna, Austria).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003ePatient cohort and transplantation details\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe evaluated 211 patients with MF who had undergone HSCT. The cohort included 145 (68.7%) patients diagnosed with primary MF, 20 (9.5%) with post-essential thrombocythemia or polycythemia vera MF, and 46 (21.8%) with MF that transformed into acute myeloid leukemia. The HSCT donor sources were distributed as follows: 66 (31.7%) patients received grafts from human leukocyte antigen-matched sibling donors (MSDs), 127 (60.2%) from Haplo donors, and 18 (8.5%) from unrelated donors. The patient characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, Median (Range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (13\u0026ndash;69)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e124 (58.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (41.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePMF, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145 (68.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-PV/ET MF, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (9.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMF-AML, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (21.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRisk (DIPSS-plus)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInt-1 risk, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (10.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInt-2 risk, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e175 (82.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh risk, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMIPSS70 v2.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate risk, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh risk, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (46.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery high risk, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (11.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot available, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79 (37.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDriver mutation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJAK2, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (33.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMPL, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCALR, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTriple negative, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (14.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79 (37.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePretransplant spleen treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSplenic irradiation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (6.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSplenectomy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (5.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePretransplant splenomegaly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo splenomegaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (11.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild splenomegaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118 (55.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMassive splenomegaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (32.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDonor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMatched sibling donor, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (31.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMatched unrelated donor, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (8.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaploidentical donor, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e127 (60.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConditioning\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBU/CY-based, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115 (54.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBU/FLU-based, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (12.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTBI-based, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (19.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStem cell sources\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePB\u0026thinsp;+\u0026thinsp;BM, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (28.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePB, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117 (55.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePB\u0026thinsp;+\u0026thinsp;BM\u0026thinsp;+\u0026thinsp;CB, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (8.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePB\u0026thinsp;+\u0026thinsp;CB, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBM, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGVHD prevention\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMTX\u0026thinsp;+\u0026thinsp;CNI\u0026thinsp;\u0026plusmn;\u0026thinsp;MMF-based\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (36.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMTX\u0026thinsp;+\u0026thinsp;CNI\u0026thinsp;\u0026plusmn;\u0026thinsp;MMF\u0026thinsp;+\u0026thinsp;ATG-based\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e132 (62.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMTX\u0026thinsp;+\u0026thinsp;CNI\u0026thinsp;\u0026plusmn;\u0026thinsp;MMF\u0026thinsp;+\u0026thinsp;PtCY-based\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDSA before transplantation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (12.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122 (57.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (29.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMNC, Median (Range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.89 (2.62\u0026ndash;15.72)\u0026times;10\u003csup\u003e8\u003c/sup\u003e/Kg\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCD34, Median (Range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.74 (0.67\u0026ndash;23.64)\u0026times;10\u003csup\u003e6\u003c/sup\u003e/Kg\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003ePMF, primary myelofibrosis; Post-PV/ET MF, polycythemia vera or essential thrombocythemia myelofibrosis; MF-AML, myelofibrosis that transformed into acute myeloid leukemia; DIPSS, Dynamic International Prognostic Scoring System; Int, intermediate; MIPSS, Mutation-Enhanced International Prognostic Score System; BU/CY, busulfan and cyclophosphamide; BU/FLU, busulfan and fludarabine; TBI, total body irradiation; PB, peripheral blood; BM, bone marrow; CB, cord blood; GVHD, graft-versus-host disease; MTX, methotrexate; CNI, calcineurin inhibitor; MMF, mycophenolate mofetil; ATG, anti-thymocyte globulin; PtCY, post-transplant cyclophosphamide; DSA, donor-specific antibodies; MNC, mononuclear cell\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eIncidence and risk factors for GF\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe Neutrophil engraftment rate at 28 days was 95.2%, and the platelet engraftment rate at 100 days was 67.8%. GF was observed in 25 patients, including 19 with primary GF and 6 with secondary GF. The cumulative incidence of GF was 12.5%. The incidence of engraftment and GF by different groups are showed in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. In the univariate analysis, massive splenomegaly (P\u0026thinsp;=\u0026thinsp;0.094), alternative donors (P\u0026thinsp;=\u0026thinsp;0.028), and the Dynamic International Prognostic Scoring System (P\u0026thinsp;=\u0026thinsp;0.068) were associated with GF. No significant associations were found with hemoglobin level (P\u0026thinsp;=\u0026thinsp;0.175), platelet count (P\u0026thinsp;=\u0026thinsp;0.300), MF grading (per WHO criteria) (P\u0026thinsp;=\u0026thinsp;0.394), donor-specific antibodies (DSA) (P\u0026thinsp;=\u0026thinsp;0.149), graft mononuclear cell (MNC) count (0.836), or CD34\u0026thinsp;+\u0026thinsp;cell count (P\u0026thinsp;=\u0026thinsp;0.101).\u003c/p\u003e \u003cp\u003eIn the multivariate analysis, massive splenomegaly (hazard ratio [HR]\u0026thinsp;=\u0026thinsp;8.627; 95% confidence interval [CI], 1.093\u0026ndash;68.068; P\u0026thinsp;=\u0026thinsp;0.041) and alternative donor HSCT (HR\u0026thinsp;=\u0026thinsp;3.529; 95% CI, 1.049\u0026ndash;11.869; P\u0026thinsp;=\u0026thinsp;0.042) were significantly associated with an elevated risk of GF. The risk factors in multivariate analysis are summarized in Table\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The cumulative incidence of GF was 4.8% in MSD recipients and 16% in alternative donor recipients (P\u0026thinsp;=\u0026thinsp;0.024). The cumulative incidence of GF in terms of splenic size was 8.3% for no splenomegaly, 10.0% for mild splenomegaly, and 18.5% for massive splenomegaly (P\u0026thinsp;=\u0026thinsp;0.19).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate analysis of graft failure\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo. of events/ evaluable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDonor source\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlternative donor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22/145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.004 (0.871\u0026ndash;10.365)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePretransplant splenomegaly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo splenomegaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild splenomegaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10/117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.703 (0.334\u0026ndash;21.891)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.351\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMassive splenomegaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14/69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.933 (0.896\u0026ndash;55.305)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDIPSS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInt-1 risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5/22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInt-2 risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16/175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.399 (0.145\u0026ndash;1.095)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4/14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.519 (0.391\u0026ndash;5.896)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.546\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eMSD, matched sibling donor; DIPSS, Dynamic International Prognostic Scoring System; Int, intermediate; HR, hazard ratio; CI, confidence interval\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe incidence of GF in Haplo recipients was 13.3%. In the Haplo setting, the univariate analysis showed that massive splenomegaly (P\u0026thinsp;=\u0026thinsp;0.004) and pretransplant white blood cell count (P\u0026thinsp;=\u0026thinsp;0.046) were associated with GF incidence. No significant associations were found with the pretransplant white blood cell count (P\u0026thinsp;=\u0026thinsp;0.404), hemoglobin level (P\u0026thinsp;=\u0026thinsp;0.275), platelet count (P\u0026thinsp;=\u0026thinsp;0.580), Dynamic International Prognostic Scoring System (P\u0026thinsp;=\u0026thinsp;0.693), MF grading (per WHO criteria) (P\u0026thinsp;=\u0026thinsp;0.213), DSA (P\u0026thinsp;=\u0026thinsp;0.300), graft MNC count (P\u0026thinsp;=\u0026thinsp;0.683), or CD34\u0026thinsp;+\u0026thinsp;cell count (P\u0026thinsp;=\u0026thinsp;0.115). In the multivariate analysis, massive splenomegaly (HR\u0026thinsp;=\u0026thinsp;4.163; 95% CI, 1.291\u0026ndash;13.427; P\u0026thinsp;=\u0026thinsp;0.017) was associated with an increased incidence of GF.\u003c/p\u003e \u003cp\u003e \u003cb\u003eOutcomes of patients with GF\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAmong the 25 patients with GF, 6 underwent secondary HSCT. Of these, 4 (66.6%) achieved successful engraftment and remained alive at the last follow-up, while the other 2 died. Among the remaining 19 patients, 6 (31%) achieved hematopoietic recovery and survived. The overall survival rate of patients with GF was 40%.\u003c/p\u003e \u003cp\u003e \u003cb\u003eOther transplantation outcomes\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAcute GVHD (grades II\u0026ndash;IV) and chronic GVHD (moderate to severe) occurred in 44% and 25% of patients, respectively. With a median follow-up duration of 734 days, the 3-year OS and DFS rates were 65.5% and 60.8%, respectively. The 3-year relapse rate was 10.1%, whereas the NRM rate was 27.8%. These transplantation outcomes are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTransplantation outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOS (3 y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDFS (3 y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCIR (3 y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNRM (3 y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGF (1 y)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall cohort\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDIPSS-plus\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInt-1 risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.76%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInt-2 risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.83%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e31.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDonor type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlternative donor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.27%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSplenomegaly\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMassive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.83%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e40.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eOS, overall survival; DFS, disease-free survival; CIR, cumulative incidence of relapse; NRM, non-relapse mortality; GF, graft failure; MSD, matched sibling donor; DIPSS, Dynamic International Prognostic Scoring System; Int, intermediate\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe univariate analysis revealed a significant association between OS and alternative donors (P\u0026thinsp;=\u0026thinsp;0.011) and massive splenomegaly (P\u0026thinsp;=\u0026thinsp;0.069). Massive splenomegaly (P\u0026thinsp;=\u0026thinsp;0.016) and alternative donors (P\u0026thinsp;=\u0026thinsp;0.059) were included in the multivariate analysis for DFS. Splenomegaly and donor type were not associated with the cumulative incidence of relapse. Pretransplant leukocyte count, hemoglobin level, platelet count, bone marrow fibrosis grade, DSA, graft MNC count, and CD34\u0026thinsp;+\u0026thinsp;cell count were not significantly associated with OS, DFS, cumulative incidence of relapse, and NRM. In the multivariate analysis, massive splenomegaly was associated with reduced DFS (HR\u0026thinsp;=\u0026thinsp;1.671; 95% CI, 1.065\u0026ndash;2.623; P\u0026thinsp;=\u0026thinsp;0.025). Alternative donors were associated with reduced OS (HR\u0026thinsp;=\u0026thinsp;2.033; 95% CI, 1.145\u0026ndash;3.611; P\u0026thinsp;=\u0026thinsp;0.015). The DFS rates were 65.9% for patients without splenomegaly, 55.8% for those with mild splenomegaly, and 49.3% for those with massive splenomegaly (P\u0026thinsp;=\u0026thinsp;0.037, log-rank test). The OS rates were 76% and 60.3% for MSD and alternative donor recipients, respectively (P\u0026thinsp;=\u0026thinsp;0.009, log-rank test). The NRM rates were 22.3% for patients without splenomegaly, 22.1% for those with mild splenomegaly, 40.6% for those with massive splenomegaly (P\u0026thinsp;=\u0026thinsp;0.030, competing risk test), 14.5% for MSD recipients, and 34.2% for alternative donor recipients (P\u0026thinsp;=\u0026thinsp;0.002, competing risk test).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAllo-HSCT is a potentially curative treatment for MF. In the current study, we demonstrated that GF remains a critical obstacle to allo-HSCT in patients with MF and that alternative donor type and pretransplant splenomegaly were associated with an increased risk of GF.\u003c/p\u003e \u003cp\u003eIn a previous report, the incidence of GF was 5\u0026ndash;20%\u003csup\u003e[15,16]\u003c/sup\u003e and was associated with a 60% mortality rate. A recent EBMT study revealed a 5-year OS rate of only 14% in patients with GF\u003csup\u003e[14]\u003c/sup\u003e, underscoring the urgent need for strategies to prevent and mitigate engraftment failure.\u003c/p\u003e \u003cp\u003ePretransplant splenomegaly is a well-established prognostic factor that influences engraftment and transplant outcomes in patients with MF\u003csup\u003e[17,18]\u003c/sup\u003e. The mechanisms underlying the impact of splenomegaly on engraftment likely involve spleen-mediated destruction of hematopoietic cells, release of proinflammatory cytokines, and enhanced immune rejection\u003csup\u003e[19]\u003c/sup\u003e. These findings highlight the need for effective pretransplant spleen management. Current EBMT guidelines recommend JAK2 inhibitors, such as ruxolitinib, as first-line therapy for pretransplant splenomegaly, with approximately 50% of patients experiencing spleen size reduction, symptom alleviation, and improved prognosis\u003csup\u003e[19,20]\u003c/sup\u003e. Second-line treatment options for patients refractory to ruxolitinib include splenic irradiation or splenectomy\u003csup\u003e[21,22]\u003c/sup\u003e. In the largest retrospective study involving 1,195 patients, pretransplant splenectomy was associated with reduced NRM but an increased risk of relapse, with no overall impact on OS. However, in high-risk subgroups or patients with massive splenomegaly, splenectomy improved OS without affecting the relapse rates\u003csup\u003e[22]\u003c/sup\u003e. The optimal approach for pretransplant spleen management and post-treatment care requires further prospective investigation.\u003c/p\u003e \u003cp\u003eHaplo donors have been suggested to be another important factor associated with GF\u003csup\u003e[8,23,24,9]\u003c/sup\u003e. In our cohort, both Haplo and unrelated donor transplants were associated with higher GF rates than MSD transplants. This observation is consistent with those of previous reports from both EBMT and Center for International Blood and Marrow Transplant Research. An elevated incidence of GF, up to 20% in Haplo transplant settings, was observed in patients with MF, contributing to considerable NRM\u003csup\u003e[7,25,26]\u003c/sup\u003e. To reduce GF rates during Haplo-HSCT, proactive management of splenomegaly, optimization of conditioning regimens, and robust prophylaxis for GVHD and infections are essential. To date, there have been few reports on Haplo-HSCT for MF. Therefore, improving the outcomes of Haplo-HSCT in patients with MF is necessary.\u003c/p\u003e \u003cp\u003eOther factors previously associated with GF, including DSAs, CD34\u0026thinsp;+\u0026thinsp;cell dose, female donors, and elevated pretransplant ferritin levels, were not significantly correlated with GF in our study\u003csup\u003e[27\u0026ndash;29,11]\u003c/sup\u003e. This lack of association may be attributed to our limited sample size, low GF event rate, or missing data, warranting further investigation in larger cohorts.\u003c/p\u003e \u003cp\u003eIn previous reports, GF was associated with a high mortality rate\u003csup\u003e[15,16]\u003c/sup\u003e. Therapeutic options for GF are limited and often result in poor outcomes. Immunosuppressive agents and hematopoietic growth factors (e.g., granulocyte colony-stimulating factor or thrombopoietin receptor agonists) are largely ineffective and result in high mortality rates\u003csup\u003e[30,31]\u003c/sup\u003e. Emerging evidence supports second transplantation and CD34 boost cell infusion as viable salvage strategies\u003csup\u003e[15]\u003c/sup\u003e. Further prospective studies are required to validate these findings.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, this was a retrospective study with a small sample size. Second, the time span was very wide; therefore, heterogeneity might have led to bias in the study. Overall, this study describes the current status of allo-HSCT for MF in China.\u003c/p\u003e \u003cp\u003eIn conclusion, allo-HSCT provides curative outcomes for patients with MF. However, GF remains a significant challenge in allo-HSCT, particularly in Haplo-HSCT and those with massive pretransplant splenomegaly. This study suggests that management of splenomegaly may improve transplantation outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eThis work was supported (in part) by the National Natural Science Foundation of China (Grant No. 8227010768), Beijing Natural Science Foundation (Grant No. 7252147), and Peking University Clinical Scientist Training Program (Grant No. BMU2025PYJH015).\u003c/p\u003e\n\u003cp\u003eDisclosure statement\u003c/p\u003e\n\u003cp\u003eAll authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003eData sharing and data availability\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGangat N, Tefferi A. Myelofibrosis biology and contemporary management[J]. British Journal of Haematology, 2020, 191(2): 152-170.\u003c/li\u003e\n\u003cli\u003eGarmezy B, Schaefer J K, Mercer J, et al. A provider\u0026rsquo;s guide to primary myelofibrosis: Pathophysiology, diagnosis, and management[J]. Blood Reviews, 2021, 45: 100691.\u003c/li\u003e\n\u003cli\u003eAbdel-Wahab O I, Levine R L. Primary myelofibrosis: Update on definition, pathogenesis, and treatment[J]. Annual Review of Medicine, 2009, 60: 233-245.\u003c/li\u003e\n\u003cli\u003eTefferi A. Primary myelofibrosis: 2021 update on diagnosis, risk-stratification and management[J]. American Journal of Hematology, 2021, 96(1): 145-162.\u003c/li\u003e\n\u003cli\u003eAyyappan S, Janakiram M, Raghupathy R. Current and emerging therapies in primary myelofibrosis[J]. Cardiovascular \u0026amp; Hematological Disorders Drug Targets, 2012, 12(1): 6-20.\u003c/li\u003e\n\u003cli\u003eGambella M, Bregante S, Raiola A M, et al. Haploidentical hematopoietic cell transplantation for myelofibrosis in the ruxolitinib era[J]. Transplantation and Cellular Therapy, 2023, 29(1): 49.e1-49.e7.\u003c/li\u003e\n\u003cli\u003eBewersdorf J P, Sheth A H, Vetsa S, et al. Outcomes of allogeneic hematopoietic cell transplantation in patients with myelofibrosis\u0026mdash;a systematic review and meta-analysis[J]. Transplantation and Cellular Therapy, 2021, 27(10): 873.e1-873.e13.\u003c/li\u003e\n\u003cli\u003eGhalehsari N, Castillo Tokumori F, Chen Z, et al. Transplant outcomes in myelofibrosis: Impact of donor type (cord blood grafts supported by CD34+ selected cells [haplo-cord] versus matched donors)[J]. Transplantation and Cellular Therapy, 2024, 30(11): 1100.e1-1100.e11.\u003c/li\u003e\n\u003cli\u003eJain T, Estrada-Merly N, Salas M Q, et al. Donor types and outcomes of transplantation in myelofibrosis: A CIBMTR study[J]. Blood Advances, 2024, 8(16): 4281-4293.\u003c/li\u003e\n\u003cli\u003eHuang X J. Overcoming graft failure after haploidentical transplantation: Is this a possibility?[J]. Best Practice \u0026amp; Research Clinical Haematology, 2021, 34(1): 101255.\u003c/li\u003e\n\u003cli\u003eAlchalby H, Yunus D R, Zabelina T, et al. Incidence and risk factors of poor graft function after allogeneic stem cell transplantation for myelofibrosis[J]. Bone Marrow Transplantation, 2016, 51(9): 1223-1227.\u003c/li\u003e\n\u003cli\u003eJungius S, Adam F C, Grosheintz K, et al. Characterization of engraftment dynamics in myelofibrosis after allogeneic hematopoietic cell transplantation including novel conditioning schemes[J]. Frontiers in Oncology, 2023, 13: 1205387.\u003c/li\u003e\n\u003cli\u003eGergis U, Kuriakose E, Shore T, et al. Allogeneic transplantation for patients with advanced myelofibrosis: Splenomegaly and high serum LDH are adverse risk factors for successful engraftment[J]. Clinical Lymphoma, Myeloma \u0026amp; Leukemia, 2016, 16(5): 297-303.\u003c/li\u003e\n\u003cli\u003eMcLornan D P, Hernandez-Boluda J C, Czerw T, et al. Allogeneic haematopoietic cell transplantation for myelofibrosis: Proposed definitions and management strategies for graft failure, poor graft function and relapse: best practice recommendations of the EBMT chronic malignancies working party[J]. Leukemia, 2021, 35(9): 2445-2459.\u003c/li\u003e\n\u003cli\u003eGiammarco S, Raiola A M, Di Grazia C, et al. Second haploidentical stem cell transplantation for primary graft failure[J]. Bone Marrow Transplantation, 2021, 56(6): 1291-1296.\u003c/li\u003e\n\u003cli\u003eOzdemir Z N, Civriz Bozdağ S. Graft failure after allogeneic hematopoietic stem cell transplantation[J]. Transfusion and Apheresis Science, 2018, 57(2): 163-167.\u003c/li\u003e\n\u003cli\u003ePolverelli N, Mauff K, Kr\u0026ouml;ger N, et al. Impact of spleen size and splenectomy on outcomes of allogeneic hematopoietic cell transplantation for myelofibrosis: A retrospective analysis by the chronic malignancies working party on behalf of european society for blood and marrow transplantation (EBMT)[J]. American Journal of Hematology, 2021, 96(1): 69-79.\u003c/li\u003e\n\u003cli\u003eLuther M, Henes F O, Zabelina T, et al. Spleen volume and length determined by computed tomography impact outcome after allogeneic stem cell transplantation for myelofibrosis[J]. Bone Marrow Transplantation, 2023, 58(7): 755-761.\u003c/li\u003e\n\u003cli\u003eGagelmann N, Bose P, Gupta V, et al. Consistency of spleen and symptom reduction regardless of cytopenia in patients with myelofibrosis treated with pacritinib[J]. Clinical Lymphoma, Myeloma \u0026amp; Leukemia, 2024, 24(11): 796-803.\u003c/li\u003e\n\u003cli\u003eLucijanic M, Krecak I, Soric E, et al. Palpable spleen size is differently prognostic in primary and secondary myelofibrosis[J]. Leukemia \u0026amp; Lymphoma, 2023, 64(4): 893-896.\u003c/li\u003e\n\u003cli\u003eGagelmann N, Hobbs G S, Campodonico E, et al. Splenic irradiation for myelofibrosis prior to hematopoietic cell transplantation: A global collaborative analysis[J]. American Journal of Hematology, 2024, 99(5): 844-853.\u003c/li\u003e\n\u003cli\u003eMalato A, Rossi E, Tiribelli M, et al. Splenectomy in myelofibrosis: Indications, efficacy, and complications[J]. Clinical Lymphoma Myeloma and Leukemia, 2020, 20(9): 588-595.\u003c/li\u003e\n\u003cli\u003eJain T, Tsai H L, Elmariah H, et al. Haploidentical donor hematopoietic cell transplantation for myelodysplastic/myeloproliferative overlap neoplasms: Results from a north American collaboration[J]. Haematologica, 2023, 108(12): 3321-3332.\u003c/li\u003e\n\u003cli\u003eYoon J H, Min G J, Park S S, et al. HLA-mismatched donor and high ferritin level showed poor clinical outcomes after allogeneic hematopoietic cell transplantation in patients with advanced myelofibrosis[J]. Therapeutic Advances in Hematology, 2020, 11: 2040620720936935.\u003c/li\u003e\n\u003cli\u003eMurata M, Takenaka K, Uchida N, et al. Comparison of outcomes of allogeneic transplantation for primary myelofibrosis among hematopoietic stem cell source groups[J]. Biology of Blood and Marrow Transplantation: Journal of the American Society for Blood and Marrow Transplantation, 2019, 25(8): 1536-1543.\u003c/li\u003e\n\u003cli\u003eMarkiewicz M, Dzierzak Mietla M, Wieczorkiewicz A, et al. Safety and outcome of allogeneic stem cell transplantation in myelofibrosis[J]. European Journal of Haematology, 2016, 96(3): 222-228.\u003c/li\u003e\n\u003cli\u003eHickey C L, Zhang M J, Allbee-Johnson M, et al. Donor type does not impact late graft failure following reduced-intensity allogeneic hematopoietic cell transplantation with post-transplant cyclophosphamide-based graft-versus-host disease prophylaxis[J]. Transplantation and Cellular Therapy, 2025, 31(3): 174.e1-174.e12.\u003c/li\u003e\n\u003cli\u003eLima A C M, Bonfim C, Getz J, et al. Untreated Donor-Specific HLA Antibodies Are Associated With Graft Failure and Poor Survival After Haploidentical Transplantation With Post-Transplantation Cyclophosphamide in Pediatric Patients With Nonmalignant Disorders[J]. Transplantation and Cellular Therapy, 2022, 28(10): 698.e1-698.e11.\u003c/li\u003e\n\u003cli\u003eXie Y, Parekh J, Tang Z, et al. Donor-specific antibodies and primary graft failure in allogeneic hematopoietic stem cell transplantation: A systematic review and meta-analysis[J]. Transplantation and Cellular Therapy, 2021, 27(8): 687.e1-687.e7.\u003c/li\u003e\n\u003cli\u003eMa R, Zhu D P, Zhang X H, et al. Salvage haploidentical transplantation for graft failure after first haploidentical allogeneic stem cell transplantation: An updated experience[J]. Bone Marrow Transplantation, 2024, 59(7): 991-996.\u003c/li\u003e\n\u003cli\u003eSun Y Q, Wang Y, Wang F R, et al. Graft failure in patients with hematological malignancies: A successful salvage with a second transplantation from a different haploidentical donor[J]. Frontiers in Medicine, 2021, 8: 604085.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bone-marrow-transplantation","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"bmt","sideBox":"Learn more about [Bone Marrow Transplantation](http://www.nature.com/bmt/)","snPcode":"41409","submissionUrl":"https://mts-bmt.nature.com/cgi-bin/main.plex","title":"Bone Marrow Transplantation","twitterHandle":"@bmtjournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"graft failure, myelofibrosis, hematopoietic stem cell transplantation","lastPublishedDoi":"10.21203/rs.3.rs-7003361/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7003361/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eGraft failure (GF) is a barrier to successful allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients with myelofibrosis (MF). We investigated the incidence, risk factors, and prognosis for GF after allo-HSCT for MF. 211 Patients with MF who underwent allo-HSCT across 32 hematology centers in China between December 2008 and December 2024 were retrospectively analyzed. Among them, 66 underwent matched sibling donor HSCT, 127 haploidentical HSCT, and 18 unrelated donor HSCT. The overall GF incidence was 12.5%. GF incidence was significantly associated with donor type (matched sibling, 4.8%; alternative, 13.3%; P\u0026thinsp;=\u0026thinsp;0.024). Pretransplant massive splenomegaly increased GF incidence (no splenomegaly, 8.3%; mild, 10%; massive, 18.5%; P\u0026thinsp;=\u0026thinsp;0.19). In multivariate analysis, splenomegaly (HR\u0026thinsp;=\u0026thinsp;8.627; P\u0026thinsp;=\u0026thinsp;0.041) and alternative donors (HR\u0026thinsp;=\u0026thinsp;3.529; P\u0026thinsp;=\u0026thinsp;0.042) increased GF risk. With median follow-up of 734 days, 3-year OS was 65.5%, DFS 60.8%, relapse rate 10.1%, NRM rate 27.8%. Multivariate analysis showed pretransplant splenomegaly reduced 3-year DFS (HR\u0026thinsp;=\u0026thinsp;1.671; P\u0026thinsp;=\u0026thinsp;0.025), and alternative donors reduced 3-year OS (HR\u0026thinsp;=\u0026thinsp;2.033; P\u0026thinsp;=\u0026thinsp;0.015). Allo-HSCT provides curative outcomes for MF patients. However, GF remains a significant challenge, particularly in haploidentical HSCT and those with massive pretransplant splenomegaly.\u003c/p\u003e","manuscriptTitle":"Incidence and Risk Factors for Graft Failure after Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Myelofibrosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-08 06:22:27","doi":"10.21203/rs.3.rs-7003361/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2025-08-06T10:52:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-08-05T15:14:53+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-07-16T16:28:00+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-07-11T12:41:10+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-07-03T17:33:43+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2025-07-03T13:22:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-03T10:33:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"Bone Marrow Transplantation","date":"2025-07-02T15:23:35+00:00","index":"","fulltext":""},{"type":"checksFailed","content":"","date":"2025-06-30T11:02:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-29T14:47:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bone-marrow-transplantation","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"bmt","sideBox":"Learn more about [Bone Marrow Transplantation](http://www.nature.com/bmt/)","snPcode":"41409","submissionUrl":"https://mts-bmt.nature.com/cgi-bin/main.plex","title":"Bone Marrow Transplantation","twitterHandle":"@bmtjournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"12984fea-7769-476b-8030-8a7237e52e69","owner":[],"postedDate":"July 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":50997745,"name":"Health sciences/Risk factors"},{"id":50997746,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-11-26T08:11:31+00:00","versionOfRecord":{"articleIdentity":"rs-7003361","link":"https://doi.org/10.1038/s41409-025-02746-4","journal":{"identity":"bone-marrow-transplantation","isVorOnly":false,"title":"Bone Marrow Transplantation"},"publishedOn":"2025-11-25 05:00:00","publishedOnDateReadable":"November 25th, 2025"},"versionCreatedAt":"2025-07-08 06:22:27","video":"","vorDoi":"10.1038/s41409-025-02746-4","vorDoiUrl":"https://doi.org/10.1038/s41409-025-02746-4","workflowStages":[]},"version":"v1","identity":"rs-7003361","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7003361","identity":"rs-7003361","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}