The success of reduced intensity conditioning (RIC)
transplantation is largely dependent on alloimmune effects. It is critical to determine whether immune modulation with
anti-T-cell antibody infusion abrogates the therapeutic benefits of
transplantation. We examined 1676 adults undergoing RIC
transplantation for
hematologic malignancies. All patients received
alkylating agent plus
fludarabine; 792 received allografts from a
human leukocyte antigen-matched sibling, 884 from
a 7 or 8 of 8 HLA-matched unrelated donor. Using Cox regression, outcomes after in vivo T-cell depletion (n = 584
antithymocyte globulin [ATG]; n = 213
alemtuzumab) were compared with T cell- replete (n = 879)
transplantation. Grade 2 to 4 acute GVHD was lower with
alemtuzumab compared with ATG or T cell- replete regimens (19% vs 38% vs 40%, P < .0001) and chronic GVHD, lower with
alemtuzumab, and ATG regimens compared with T-replete approaches (24% vs 40% vs 52%, P < .0001). However, relapse was more frequent with
alemtuzumab and ATG compared with T cell-replete regimens (49%, 51%, and 38%, respectively, P < .001). Disease-free survival was lower with
alemtuzumab and ATG compared with T cell-replete regimens (30%, 25%, and 39%, respectively, P < .001). Corresponding probabilities of overall survival were 50%, 38%, and 46% (P = .008). These data suggest adopting a cautious approach to routine use of in vivo T-cell depletion with RIC regimens.