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related donor should be considered for this procedure as first-line therapy. In this group of patients the outcome of an allogeneic SCT is superior to that of immunosuppressive therapy, with a 75-90% chance of long-term survival. In addition, unlike with immunosuppressive therapy, there is a much lower risk of late relapses and development of clonal disorders. Conditioning regimens for patients undergoing an HLA-identical related donor should preferably be free of irradiation, and it appears that cyclophoshamide combined with ATG is optimal in this setting. Preliminary retrospective analyses suggest that for HLA-identical related transplants for AA, the use of PBSC is associated with a worse outcome compared to bone marrow. Alternate donors should not be considered for front-line therapy and should be limited to patients who have failed immunosuppressive therapy. For alternate donor transplants, the use of cyclophos-phamide with ATG as a conditioning regimen is probably inadequate and further intensification is justified to reduce the risk of graft rejection and improve outcomes. Figure 42.3 outlines an algorithm that could be used to decide on the appropriate management of a patient with SAA or VSAA.

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