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\begin{document}

\title{The Effect of ABO Blood Group Incompatibility on Hematopoietic Stem Cell
Transplantation in Children with Aplastic Anemia}



\author[1]{Zuofeng Li}%
\author[2]{hao xiong}%
\author[2]{Zhi Chen}%
\author[3]{Ming Sun}%
\author[3]{Wenjie Lu}%
\author[3]{Shan-shan Qi}%
\author[2]{Fang Tao}%
\author[2]{Linlin Luo}%
\affil[1]{Wuhan University of Science and Technology School of Medicine}%
\affil[2]{Wuhan Children’s Hospital Tongji Medical College Huazhong University of Science and Technology}%
\affil[3]{Wuhan Children’s Hospital}%


\vspace{-1em}



  
  \date{May 20, 2024}


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\selectlanguage{english}
\begin{abstract}
The influence of ABO incompatibility on transplant results in juvenile
aplastic anemia (SAA) children receiving hematopoietic stem cell
transplantation (HSCT) is debated, and no published data are available.
This study involved 85 children with AA who received hematopoietic stem
cell transplants from donors who were ABO-compatible (n = 38), major
ABO-incompatible (n = 17), minor ABO-incompatible (n = 21), and
bi-directionally incompatible (n = 9). Except for a statistical
difference in acute graft-versus-host disease (aGVHD), the four groups
did not have significantly different chronic GVHD, overall survival, and
neutrophil and platelet implantation rates, and no pure red cell aplasia
or passenger lymphocyte syndrome. Therefore, we inferred that ABO blood
group-incompatible donors do not significantly affect HSCT outcomes and
are not a barrier.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Aplastic anemia (AA) {[}1{]} is a common and potentially
life-threatening condition in children that leads to bone marrow loss.
The two main AA treatment options are hematopoietic stem cell
transplantation (HSCT) and immunosuppressive therapy. However,
immunosuppressive treatment effectiveness is limited due to
non-responsiveness, relapse, and clonal evolution. Therefore, allogeneic
HSCT is recommended as the first-line treatment for patients aged
\textless{}40 years with a matched sibling donor (MSD). HSCT {[}2{]} is
currently the primary cell treatment used for therapeutic purposes in
both malignant and nonmalignant hematologic disorders. Transplantation
success is influenced by sex, human leukocyte antigen (HLA)
compatibility, donor age, and cytomegalovirus (CMV) status. However, the
effect of ABO compatibility remains debated {[}3-4{]}. Particularly, it
is uncertain whether ABO incompatibility affects HSCT outcomes in
high-risk groups, such as patients who have received long-term
transfusion treatment. Existing knowledge about ABO-mismatched
transplantation in pediatric HSCT is mostly based on studies on adults.
Therefore, we investigated the effect of donor--recipient ABO blood type
matching on the outcomes of pediatric patients with severe AA receiving
HSCT. This is the first report to address this specific research
question.

\textbf{Methods}

Patients

Between August 2016 and June 2023, 85 children diagnosed with AA who
underwent allogeneic HSCT were included in this study. The patients were
treated at the pediatric stem cell transplantation unit of Wuhan
Children's Hospital. ABO compatibility was documented in 38
donor--recipient pairs, while ABO incompatibility was documented in 47
pairs (17 major, 21 minor, 9 bi-directional).

The protocol of this clinical observation study adhered to the tenets of
the Declaration of Helsinki and received approval from the Wuhan
Children's Hospital Ethics Committee (approval no. 2022R071-E01).
Written informed consent was obtained from all patients in accordance
with the principles of the Declaration of Helsinki.

Donor mobilization and stem cell harvesting

For donor mobilization and stem cell harvesting, the donors received a
5--10 \selectlanguage{greek}µ\selectlanguage{english}g/kg infusion of granulocyte colony-stimulating factor (G-CSF)
for 5 days before transplantation. Peripheral blood stem cells (PBSCs)
were collected on days 4 and 5. Mobilization was considered successful
when the CD34 cell count was 4--6 \selectlanguage{ngerman}× 10\textsuperscript{6}/kg and the
mononuclear cell (MNC) count was 6--8 × 10\textsuperscript{8}/kg.

Prophylactic treatment for graft-versus-host disease

The prophylactic treatment for graft-versus-host disease (GVHD) followed
the current standard of care. A combination of cyclophosphamide (Cy) and
anti-thymocyte globulin (ATG) was used for MSD-HSCT (matched sibling
donor HSCT). Anti-CD25 monoclonal antibodies were added for UD-HSCT
(unrelated donors HSCT). In the HID-HSCT (haploidentical HSCT) group,
methotrexate (MTX), ,mycophenolate mofetil (MMF), and an anti-CD25
monoclonal antibody were used based on previous recommendations {[}5{]}.

Definitions

AA is characterized by pancytopenia and hypocellular bone marrow without
abnormal infiltrate or marrow fibrosis {[}6{]}. ABO blood type
compatibility between the donor and patient is crucial in blood group
systems {[}7{]}. ABO iso-group (match) refers to donors and patients
with the same ABO blood types {[}8{]}. The major ABO-incompatible group
consists of iso-agglutinins directed against donor red blood cell
antigens from type A, AB, or B donors to type O recipients. The minor
ABO-incompatible group consists of iso-agglutinins directed against red
blood cell antigens from type O donors to type A, B, or AB recipients.
Bidirectional ABO incompatibility, e.g., type A donor to type B
recipient, occurs when iso-agglutinins are present against both the
donor and patient red blood cell antigens. OS (overall survival) was
measured from the first day of therapy until death or the last
follow-up. GFFS (graft failure-free survival) was defined as survival
without grade III--IV acute GVHD (aGVHD), moderate-to-severe chronic
GVHD (cGVHD), or treatment failure, including death, primary or
secondary graft failure, and relapse {[}9{]}. Neutrophil engraftment was
defined as an absolute neutrophil count \textgreater{} 0.5 ×
10\textsuperscript{9}/L for three consecutive days. Platelet engraftment
was defined as an absolute platelet count \textgreater{} 20 ×
10\textsuperscript{9}/L for three consecutive days without transfusion.
Failure to achieve engraftment by day +28 was considered indicative of
low donor chimerism, and primary graft failure was assumed in such
cases. The diagnostic and classification criteria for aGVHD and cGVHD
were based on the Glucksberg-Seattle criteria {[}10,11{]}.TA-TMA is
diagnosed and treated according to the criteria proposed by the IWG
(International Working Group){[}12{]}.

\textbf{Results}

Patient characteristics

Table 1 summarizes the patient characteristics. This retrospective study
involved 85 patients (median follow-up: 29 months; range: 6--82 months).
The cohort consisted of 43 boys and 42 girls (median age: 6.1 years; age
range: 1--16.9 years). ABO compatibility was documented in 38
donor--recipient pairs, while ABO incompatibility was documented in 47
donor--recipient pairs (17 major, 21 minor, and 9 bi-directional
incompatible pairs). Analysis of the study cohort overall revealed no
statistically significant differences for all parameters.

Overall results

The 6-year OS estimates for the ABO-matched, major incompatible, minor
incompatible, and bidirectional incompatible groups were 86.59 ± 3.31\%,
94.12 ± 1.47\%, 87.91 ± 4.04\%, and 100 ± 0\%, respectively (\emph{P} =
0.2540) (Fig. 1). Of the total cohort, 18 patients died, with the causes
of mortality being cGVHD, severe infection, and TMA.

Engraftment

Platelet engraftment was observed at a median 16 days after allogeneic
HSCT. Platelet engraftment occurred in 38 patients in the ABO-matched
group (range, 14.3--18.1 days), 43 cases in the major incompatibility
group (range, 13.1--19.3 days), 21 patients in the minor incompatibility
group (range, 13.9--19.3 days), and nine patients in the bidirectional
incompatibility group (range, 11.9--16.8 days) (\emph{P} = 0.698). The
cumulative incidences of 100-day platelet engraftment were 97.37\%,
100\%, 90.48\%, and 100\% for the respective groups (\emph{P} = 0.3451).
Only one case of neutrophil engraftment failure was observed in the
ABO-matched group, while the rest were successfully engrafted.

GVHD

Of the 85 patients evaluated, 24 patients (28.2\%) experienced aGVHD,
while seven patients (8.2\%) developed moderate to severe (grades
II--IV) aGVHD. Among the evaluated patients, 13 (15.3\%) developed
cGVHD. The aGVHD incidence differed statistically across the four
groups, while that of cGVHD did not (Fig. 2). The cumulative incidences
of grade II--IV aGVHD were 13.33\% and 27.28\% in the ABO-compatible and
-major incompatibility groups, respectively, while the other groups had
0\% incidence (\emph{P} = 0.258).

Univariate and multivariate analysis

The univariate analyses determined that the survival outcomes for the
entire population were significantly associated with the occurrence of
TMA and aGVHD, but other factors did not have a significant influence on
survival (Table 2).

\textbf{Discussion}

There is consensus that ABO incompatibility causes immune complications
after HSCT (pure red cell regenerative arrest {[}PRCA{]} and early or
delayed hemolysis). However, conflicting data persist regarding the
effect of ABO incompatibility on complications such as post-transplant
survival and GVHD incidence and severity {[}13,14{]}. Few studies
addressed survival after ABO-incompatible allogeneic peripheral blood
stem cell transplantation (PBSCT) in AA patients, and this group of
children is even less well known. Therefore, we analyzed the clinical
outcome of ABO incompatibility after allo-HSCT.

A clinical study {[}15{]} reported that AA patients might produce more
cytotoxic T cells sensitive to donor major histocompatibility complexes
(MHCs) during allogeneic HSCT due to repeated transfusions. This
increase in cytotoxic T cells can lead to a higher implantation failure
rate and transplantation-related mortality. However, we determined that
the 6-year OS rate was higher in patients with bidirectional
incompatibility compared to those with the major incompatibility, minor
incompatibility, and ABO-compatible groups. However, the four data
groups were not significantly different, which was consistent with most
current findings {[}16,17{]}.

The ABO blood group system is considered the most important of the 36
blood group systems. ABO antigens are tissue blood group antigens and
can be found in the endothelium, epidermal, mucosal epithelium, and on
lymphocytes and platelets. In the present study, we observed no
difference in the neutrophil and platelet implantation status among the
four groups, which was consistent with previous findings {[}18,19{]}.
This suggested that ABO blood group incompatibility did not affect
leukocyte or platelet recovery.

Previous studies suggested that ABO-incompatible transplantation might
increase GVHD risk due to the expression of blood cell antigens on
endothelium and epithelial tissues, which the GvH response can target
{[}20{]}. However, our data revealed a significant difference in the
aGVHD incidence among the four groups (p = 0.0462). Surprisingly, the
ABO-compatible recipients had the highest incidence of aGVHD,
contradicting most previous conclusions {[}21,22{]}. Both studies
suggested that ABO incompatibility increases the risk of aGVHD,
particularly in secondary ABO incompatibility. Our data suggested that
cGVHD occurrence was not associated with the presence or absence of ABO
compatibility.

ABO incompatibility increases the risk of immune-mediated hematologic
events, including hemolytic responses, passenger lymphocyte syndrome
(PLS), and PRCA, due to immunological incompatibility between donors and
recipients. A hemolytic response can occur in both major and minor
ABO-incompatible transplants. However, it can be successfully avoided
through antibody removal treatment or grafts with removed red blood
cells. PLS is more commonly observed in small ABO-incompatible
transplants with limited prevalence and is generally reported in case
studies {[}1{]}. PRCA is more prevalent in large ABO-incompatible
transplants (prevalence: 1--7.5\%) {[}23,24{]}. None of these
complications were observed in our patients during graft infusion. The
absence of these complications in our study could be attributed to
variations in primary conditions across research sites or individuals.

The univariate analysis demonstrated that aGVHD and TMA significantly
affected survival, while ABO compatibility did not exhibit a significant
effect. These findings contradicted the results reported by Helming
{[}15{]} and other studies conducted on youngsters. Although we included
a substantial number of affected children, the limited number of AA
children (n = 37, 17.1\%) might have influenced the inconsistent
outcomes. Therefore, it is crucial to conduct multicenter investigations
to validate or challenge our findings.

One strength of our study is its focus on a consistent cohort of
children with AA, which distinguishes it from most previous studies in
the field. Unlike current research that includes a broader range of
disorders and examines all HSCT recipients, we specifically examined the
effect of ABO compatibility on children with AA. This distinction might
explain the differences between our analysis results and some recent
outcomes. However, a weakness of our study is that it is a retrospective
analysis, which inherently carries the bias of examining retrospective
data. Factors that were not studied, such as ABH secretory state, graft
mononuclear cell composition, or the presence of donor-specific anti-HLA
antibodies, can all influence graft failure and rejection. These factors
might moderate the effect of ABO incompatibility on the final clinical
outcome of children undergoing allogeneic HSCT. Based on this
retrospective assessment, we concluded that ABO incompatibility has
minimal effects on HSCT efficiency and is not a significant barrier to
donor selection.

\textbf{Acknowledgments}

Data availability statement: The data generated and analyzed in the
present study can be made available by the corresponding author upon
reasonable request.

Financial disclosure: This study did not receive any funding.

Conflict of interest disclosure: There are no conflicts of interest to
report.

Ethics approval statement: Written informed consent from the
participants' legal guardian/next of kin was obtained for participation
in this study, in accordance with the national legislation and the
institutional requirements. The protocol of this clinical observation
study was approved by the Ethics Committee of Wuhan Children's Hospital
(approval no. 2022R071-E01).

Patient consent statement: Written informed consent was obtained from
the patients or their relatives before the procedures were conducted.

\textbf{References}

\begin{enumerate}
\tightlist
\item
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  Hartung HD, Olson TS, Bessler M. Acquired aplastic anemia in children.
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\end{enumerate}

\textbf{Table}

Table 1. Patient characteristics\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Variable}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{ABO-matched}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Major MM}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Minor MM}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Bi-Dir MM}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
P\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Patients, n}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
38 (44.7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
17 (20.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
21 (24.7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9 (10.6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\textbf{Age, years} \selectlanguage{ngerman}\textbf{(median ± SD)}\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
6.73 \selectlanguage{ngerman}± 3.3\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
7.58 \selectlanguage{ngerman}± 3.75\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
5.8 \selectlanguage{ngerman}± 3.82\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
6.77 \selectlanguage{ngerman}± 4.41\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\textbf{0.521}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Sex}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.674\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Male/female\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
22/16\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
8/9\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9/12\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4/5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Disease classification}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.132\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
SAA\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
25 (65.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10 (58.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
16 (76.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9 (100.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
VSAA\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
13 (34.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
7 (41.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5 (23.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0 (0.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Donor type}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.690\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
HID\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
16 (42.1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10 (58.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
11 (52.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4 (44.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
MSD\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6 (15.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1 (5.9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3 (14.3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0 (0.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
UD\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
16 (42.1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6 (35.3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
7 (33.3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5 (55.6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Ferr (range)}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
849.4 (627.1--1071.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2195.0 (-1085.8 to 5475.8)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1377.9 (494.2--2261.6)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
741.1 (394.9--1087.2)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.701\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\selectlanguage{ngerman}\textbf{MNC, ×10\textsuperscript{8}/L (median ± SD)}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
8.2 \selectlanguage{ngerman}± 1.2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
8.5 \selectlanguage{ngerman}± 3.5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
8.7 \selectlanguage{ngerman}± 1.5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
8.3 \selectlanguage{ngerman}± 1.3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.844\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\selectlanguage{ngerman}\textbf{CD34, ×10\textsuperscript{6}/L (median ± SD)}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6.0 \selectlanguage{ngerman}± 2.6\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5.7 \selectlanguage{ngerman}± 2.5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5.3 \selectlanguage{ngerman}± 2.2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4.3 \selectlanguage{ngerman}± 1.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.281\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Neutrophil engraftment}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
13.0 (12.9--14.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
12.0 (12.4--15.0)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
13.0 (12.3--15.6)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
13.0 (11.8--14.0)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.896\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\textbf{Platelet}\\
\textbf{engraftment}\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
16.2 \selectlanguage{ngerman}± 5.7\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
16.2 \selectlanguage{ngerman}± 6.0\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
16.6 \selectlanguage{ngerman}± 5.6\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
14.3 \selectlanguage{ngerman}± 3.2\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
0.785\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{aGVHD classification}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
15 (39.5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3 (17.7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5 (23.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1 (11.1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.186\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{cGVHD classification}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5 (13.2\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2 (11.76\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5 (23.81\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1 (11.1\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.740\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Follow-up period, months}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
30.2 \selectlanguage{ngerman}± 23.4\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
30.9 \selectlanguage{ngerman}± 22.2\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
32.6 \selectlanguage{ngerman}± 14.0\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
38.7 \selectlanguage{ngerman}± 19.5\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.529\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Bi-Dir MM: Bidirectional mismatch; MM: mismatch; Ferr: ferritin

Table 2. Univariate and multivariate analyses\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\textbf{Variables} & \textbf{Univariate analysis} & \textbf{Univariate
analysis} & \textbf{Multivariate analysis} & \textbf{Multivariate
analysis}\tabularnewline
& P & \textbf{OR (95\% CI)} & P & \textbf{OR (95\% CI)}\tabularnewline
\textbf{Age} & 0.992 & 1.001 (0.818--1.224) & - & -\tabularnewline
\textbf{Male} & 0.165 & 0.308 (0.059--1.624) & - & -\tabularnewline
\textbf{ABO-matched} & 0.436 & 0.413 (0.044--3.830) & - &
-\tabularnewline
\textbf{SAA} & 0.774 & 0.783 (0.147--4.170) & - & -\tabularnewline
\textbf{HID-HSCT} & 0.779 & 0.432 (0.067--2.782) & - & -\tabularnewline
\textbf{aGVHD} & \textbf{0.036} & \textbf{5.088 (1.110--23.314)} & 0.104
& 3.831 (0.760--19.307)\tabularnewline
\textbf{cGVHD} & 0.818 & 0.774 (0.087--6.872) & - & -\tabularnewline
\textbf{HBP} & 0.648 & 1.690 (0.177--16.118) & - & -\tabularnewline
\textbf{TMA} & \textbf{0.036} & \textbf{8.222 (1.143--59.146)} & 0.167 &
4.422 (0.536--36.466)\tabularnewline
\textbf{N engraftment} & 0.610 & 0.922 (0.675--1.260) & - &
-\tabularnewline
\textbf{PLT engraftment} & 0.650 & 0.966 (0.831--1.123) & - &
-\tabularnewline
\textbf{Ferritin} & 0.984 & 1.000 (1.000--1.000) & &\tabularnewline
\textbf{MNC} & 0.701 & 1.066 (0.769--1.478) & &\tabularnewline
\textbf{CD34} & 0.912 & 0.983 (0.721--1.340) & &\tabularnewline
\bottomrule
\end{longtable}

\textbf{Figures}

Figures 1. Kaplan--Meier plot of OS according to treatment group\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figures 2. Cumulative incidence plots for (a) aGVHD and (b) cGVHD\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

