Upfront Alternative Donor Transplant versus Immunosuppressive Therapy in Patients with Severe Aplastic Anemia Who Lack a Fully HLA-Matched Related Donor: Systematic Review and Meta-Analysis of Retrospective Studies, on Behalf of the Severe Aplastic Anemia Working Party of the European Group for Blood and Marrow Transplantation

•Hematopoietic stem cell transplantation from a matched sibling donor (MSD) is the standard of care treatment for children and young adults with severe aplastic anemia (SAA).•Limitations in identifying an MSD, together with recent advancement in the form of adding post-transplantation cyclophosphamide to alternative donor transplantation (ADT), compel a contemporary reevaluation.•In this metanalysis, the pooled 5-year overall survival was in favor of upfront ADT compared with immunosuppressive therapy (odds ratio [OR], 0.44) and in favor of upfront ADT compared with salvage ADT (OR, 0.31).•Upfront ADT is a potential alternative treatment option in pediatric and young adult patients with SAA who lack an HLA MRD.