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Improved GVHD-free relapse-free survival when rATG/ATLG is used in allo-HCT from matched sibling donors - an EBMT registry study by the Transplant Complications Working Party

Bone Marrow Transplantation volume 60, pages 1574–1583 (2025)Cite this article

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Abstract

The EBMT recommends rabbit anti-thymocyte or anti-T-lymphocyte globulin (rATG/ATLG) as GVHD prophylaxis in matched sibling donor (MSD) allogeneic hematopoietic cell transplantation (allo-HCT). However, discrepancies between recommendations and clinical practice were reflected in the EBMT survey. Therefore, we performed retrospective EBMT registry analysis from 2014 to 2021 to reinforce the real-world evidence context of rATG/ATLG impact on post-transplantation outcomes. This study included 11,420 adult patients (non-ATG n = 7680 and ATG n = 3740) with hematological malignancies after the first allo-HCT from peripheral blood. Use of ATG was associated with a reduced risk of aGVHD II-IV (Day +100: non-ATG vs ATG, 27.6% vs. 21.6%; adjusted HR 0.7, p < 0.001) and cGVHD (2-year: non-ATG vs ATG, 48.9% vs 30%; adjusted HR 0.45, p < 0.001), improved OS (2-year: 62.9% vs 63.3%; adjusted HR 0.89, p = 0.009), reduced NRM (2-year: 16% vs 12.5%; adjusted HR 0.63, p < 0.001), and higher GRFS (2-year: 32.2% vs 40.7%; adjusted HR 0.72, p < 0.001). While RI was higher in the ATG group (2-year: non-ATG vs ATG, 30.2% vs 34.7%; adjusted HR 1.22, p < 0.001) it did not translate into a significantly lower PFS (2-year: 53.9% vs 52.8%; adjusted HR not significant). Overall, outcomes were favorable for the intermediate rATG/ATLG dose ranges compared to the low and high dose ranges. Administration of rATG/ATLG improved outcomes in MSD allo-HCT recipients, supporting the EBMT recommendation for its use.

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Fig. 1: Transplantation outcomes depending on ATG use: GVHD-related parameters.
Fig. 2: Transplantation outcomes depending on ATG use: survival parameters and relapse.

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Author information

Authors and Affiliations

  1. Department of Hematology and Transplantology, University Clinical Center, Medical University of Gdańsk, Gdańsk, Poland

    Agnieszka Piekarska & Jan Maciej Zaucha

  2. EBMT Paris Study Office / CEREST-TC, INSERM UMR-S 938, Sorbonne University, Hôpital Saint Antoine, Paris, France

    Mouad Abouqateb, William Boreland & Christophe Peczynski

  3. Department for Stem Cell Transplantation, University Medical Center, Hamburg, Germany

    Nicolaus Kröger

  4. University Medical Center Freiburg, University of Freiburg, Freiburg, Germany

    Robert Zeiser

  5. IRCCS Ospedale San Raffaele s.r.l., Milano, Italy

    Fabio Ciceri

  6. University Hospital Essen, Essen, Germany

    Thomas Schroeder

  7. University of Heidelberg, Heidelberg, Germany

    Thomas Luft

  8. University Hospital Basel, Basel, Switzerland

    Jakob Passweg

  9. University Hospital TU Dresden, Dresden, Germany

    Desiree Kunadt

  10. University of Muenster, Muenster, Germany

    Matthias Stelljes

  11. Charité – Department of Hematology, Oncology and Tumorimmunology, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany

    Igor Wolfgang Blau & Olaf Penack

  12. Medical Clinic and Policinic 1, Leipzig, Germany

    Uwe Platzbecker

  13. CHU de Lille, Univ Lille, INSERM U1286, Infinite, Lille, France

    Ibrahim Yakoub-Agha

  14. Transplantation & Cellular Therapy, Department of Hematology, Institut Paoli Calmettes, Management Sport Cancer Lab, Lumin, Aix Marseille University, Marseille, France

    Didier Blaise

  15. IRCCS Ospedale Policlinico San Martino, Genova, Italy

    Anna Maria Raiola

  16. Klinikum Grosshadern, Munich, Germany

    Johanna Tischer

  17. University Medical Center Mainz, Mainz, Germany

    Eva Maria Wagner-Drouet

  18. University Hospital Erlangen, Erlangen, Germany

    Julia Winkler

  19. Klinikum Augsburg, Augsburg, Germany

    Christoph Schmid

  20. Universitaetsklinikum Goettingen, Goettingen, Germany

    Gerald Wulf

  21. University of Regensburg, Regensburg, Germany

    Matthias Edinger

  22. University Hospital Gasthuisberg, Leuven, Belgium

    Johan Maertens & Hélène Schoemans

  23. Division of Stem Cell Transplantation and Cellular Immunotherapies, University Hospital Schleswig-Holstein, Campus Kiel, Kiel University, Kiel, Germany

    Friedrich Stölzel

  24. Institute of Hematology and Blood Transfusion, Prague, Czech Republic

    Jan Vydra

  25. Charles University Hospital, Hradec, Czech Republic

    Pavel Zak

  26. RM Gorbacheva Research Institute, Pavlov University, St Petersburg, Russian Federation

    Ivan Moiseev

  27. University Hospital Centre Rijeka and School of Medicine, University of Rijeka, Rijeka, Croatia

    Zinaida Peric

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  1. Agnieszka Piekarska
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Contributions

AP: concept and design of a study, interpretation of the results, reference search, writing a manuscript, preparing tables and figures; MA: Registry data preparation, statistical analysis, preparing tables and figures, drafting and critical revision of the manuscript; WB: Registry data preparation, statistical analysis, drafting and critical revision of the manuscript; ChP: Registry data preparation, statistical analysis, drafting and critical revision of the manuscript; JMZ: concept of a study, interpretation of the results, drafting and critical revision of the manuscript; NK: drafting and critical revision of the manuscript; RZ: critical revision of the manuscript; FC: drafting and critical revision of the manuscript; TS: critical revision of the manuscript; TL: critical revision of the manuscript; JP: critical revision of the manuscript; DK: critical revision of the manuscript; MS: critical revision of the manuscript; IWB: critical revision of the manuscript; UP: critical revision of the manuscript; IJ-A: critical revision of the manuscript; DB: critical revision of the manuscript; AMR: critical revision of the manuscript; JT: critical revision of the manuscript; EMW-D: critical revision of the manuscript; JW: critical revision of the manuscript; ChS: critical revision of the manuscript; GGW: critical revision of the manuscript; ME: critical revision of the manuscript; JM: critical revision of the manuscript; FS: critical revision of the manuscript; JV: critical revision of the manuscript; PZ: critical revision of the manuscript; IM: drafting and critical revision of the manuscript; HS: drafting and critical revision of the manuscript; OP: drafting and critical revision of the manuscript; ZP: drafting and critical revision of the manuscript. All authors approved the final version.

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Correspondence to Agnieszka Piekarska.

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Competing interests

Nothing to declare for this topic, except potential relatedness to HCT/GVHD topics: AP has received honoraria or travel support from Alexion, AstraZeneca, Astellas, Gilead, MSD, Novartis, Pierre Fabre, Pfizer, Sanofi, and the EBMT (European Society for Blood and Marrow transplantation) which not directly related to this work. NK received honorarium from Mallinckrodt, Novartis, Kit/Gilead, BMS, Takeda, Medac, Neovii, Sanofi IYA: received honoraria from Gilead/Kite, BMS, Novartis and AstraZeneca. EMW-D reports personal fees from Novartis, Takeda, Janssen, Incyte, MEDAC. FS has received travel support from Janssen and Medac, honoraria from Medac, GWT, Abbvie, Servier and Pierre Fabre and research funding from Medac and Servier. HS reports having received personal fees from Incyte, Janssen, Novartis, Sanofi and from the Belgian Hematological Society (BHS), as well as research grants from Novartis and the BHS, all paid to her institution and not directly related to this work. She has also received non-financial support (travel grants) from Gilead, Pfizer, EBMT and the CIBMTR (Center for International Bone Marrow Transplantation Research). OP has received honoraria or travel support from Gilead, Jazz, MSD, Neovii, Novartis, Pfizer and Therakos. He has received research support from Incyte and Priothera. He is member of advisory boards to Equillium Bio, Jazz, Gilead, Novartis, MSD, Omeros, Priothera, Sanofi, Shionogi and SOBI. RZ reports having received personal fees from Incyte, MNK, Novartis, Sanofi, Medac and Neovii.

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Piekarska, A., Abouqateb, M., Boreland, W. et al. Improved GVHD-free relapse-free survival when rATG/ATLG is used in allo-HCT from matched sibling donors - an EBMT registry study by the Transplant Complications Working Party. Bone Marrow Transplant 60, 1574–1583 (2025). https://doi.org/10.1038/s41409-025-02692-1

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