TRANSPLANTATION AND CELLULAR ENGINEERING Desensitization with plasma exchange in a patient with human leukocyte antigen donor-specific antibodies before T-cell–replete haploidentical transplantation Stefania Bramanti, 1 Angela Nocco, 2 Elisa Mauro, 3 Giuseppe Milone, 3 Lucio Morabito, 1 Barbara Sarina, 1 Roberto Crocchiolo, 1 Inna Timofeeva, 1 Rossana Capizzuto, 1 Carmelo Carlo-Stella, 4 Armando Santoro, 4 and Luca Castagna 1 BACKGROUND: The presence of human leukocyte antigen donor-specific antibodies (DSAs) increases the risk of graft failure in T-cell–replete haploidentical hematopoietic stem cell transplantation (haplo-HSCT) CASE REPORT: A 49-year-old female with high-risk acute myeloid leukemia in first complete remission received a haplo-HSCT from her daughter. Pretransplant recipient screening examination showed high DSAs levels against unshared class I leukocyte antigens. RESULTS: The patient underwent a desensitization program consisting of plasma exchange (PEX), polyvalent intravenous (IV) immunoglobulins, and IV tacrolimus and mycophenolate mofetil (MMF). This protocol resulted in the disappearance of the DSA anti HLA B41. Engraftment was prompt with stable full donor chimerism. CONCLUSIONS: This case report suggests that the adopted scheme is safe for reducing DSA levels and facilitating donor engraftment in patients scheduled for haplo-HSCT. A llogeneic hematopoietic stem cell transplanta- tion (allo-HSCT) is effective in the treatment of many advanced hematologic malignancies. In the absence of a matched related donor (MRD) or matched unrelated donor (MUD), alternative donors, such as a mismatched unrelated donor (mmUD), cord blood unit (CBU), and haplo family, are considered. How- ever, with alternative donors, the risk of immunologic complications, mainly graft-versus-host disease (GVHD) and host-versus-graft reaction, increases significantly. 1,2 Graft failure (GF) is a life-threatening condition that can occur because of either a lack of initial engraftment of donor cells (primary GF) or loss of donor cells after the initial engraftment (secondary GF). The risk of mortality is very high due to infectious complications, and salvage ABBREVIATIONS: allo-HSCT 5 allogeneic hematopoietic stem cell transplantation; CBU(s) 5 cord blood unit(s); DSA(s) 5 donor-specific antibody(-ies); FLAG 5 fludarabine and cytarabine; GF 5 graft failure; haplo-HSCT 5 haploidentical hematopoietic stem cell transplantation; MMF 5 mycophenolate mofetil; mmUD 5 mismatched unrelated donor; MRD 5 matched related donor; MUD 5 matched unrelated donor; PEX 5 plasma exchange. From the 1 Bone Marrow Unit and the 4 Hematology Department, Humanitas Cancer Center, Istituto Clinico Humanitas, Rozzano, Italy; the 2 Immuno-Hematology Laboratory, IRCCS Ospedale Maggiore, Milano, Italy; and the 3 Transplant Unit Ospedale Ferrarotto, Catania, Italy. Address reprint requests to: Stefania Bramanti, Via Manzoni 56, Rozzano 89100 Milano, Italy; e-mail: stefania. bramanti@humanitas.it. Received for publication June 9, 2015; revision received October 14, 2015; and accepted October 19, 2015. doi:10.1111/trf.13523 V C 2016 AABB TRANSFUSION 2016;56;1096–1100 1096 TRANSFUSION Volume 56, May 2016