Due to the negative impact of donor-specific, anti-HLA antibodies (DSAs) on engraftment and outcome after allogeneic hematopoietic stem cell transplantation, screening is now recommended before transplantation in order to select an alternative donor or administer a desensitization treatment in the case of detection of such antibodies. Since the permissive level of DSAs is currently matter of debate, the present Editorial aims at strengthening the message about the importance of looking for their presence before transplantation and at providing a proposal on the definition of immunological risk based not only on the quantity and the spectrum of DSAs but also on other main clinical and transplant variables; indeed, the deleterious effect of DSAs is heterogeneous across the donor type, conditioning regimen, underlying disease, to cite some of the variables.

By relancing a collaborative alliance between clinicians and immunogenetic specialists, this Editorial would contribute to go beyond the case-by-case definition of immunological risk for a determined patient-donor pair and go toward an evidence-based, shared risk stratification based on multiple, but defined, characteristics as outlined in the text. This stratification would allow for the modulation of the desensitization strategies, by adapting the intensity of immunosuppression to the estimated risk of engraftment failure.



Roberto Crocchiolo - Servizio di Immunoematologia e Medicina Trasfusionale, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy https://orcid.org/0000-0001-8473-202X

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