Haploidentical stem cell transplantation: Comparing Indian and American perspectives

Haploidentical stem cell transplantation (HID-SCT) has become an essential alternative for patients without matched donors. The use of posttransplant cyclophosphamide (PTCy) has transformed graft-versus-host disease (GVHD) management, expanding global access to allogeneic SCT. This review compares HID-SCT practices and outcomes between India and the United States and proposes strategies to address India’s survival disparities. Data from 2010–2022 encompassing adult and pediatric cohorts were analyzed, focusing on conditioning intensity, graft source, GVHD prophylaxis, and supportive care. In the U.S., 23% of first SCTs in 2021 were haploidentical, with 91% utilizing PTCy and achieving 3-year overall survival (OS) of 56.6%. Myeloablative conditioning (MAC) with PK-guided busulfan and strong mid-level staffing ensures robust outpatient care. India, with ~ 150 SCT centers, favors HID-SCT due to limited registries and lower PTCy costs. However, 2-year OS ranges from 38% to 64%, hampered by reduced intensity conditioning predominance, graft failure, infections, and variable care infrastructure. To improve outcomes, India must adopt PK-guided MAC regimens, expand cytomegalovirus prophylaxis with letermovir, standardize graft dosing, enhance antimicrobial stewardship, build national registries, train outpatient care providers, and leverage telemedicine for long-term management.