Prospective Study of Targeted Busulfan–Fludarabine Conditioning for Hematopoietic Stem Cell Transplantation in Genetic Rare Diseases

Abstract

ABSTRACT Objectives Genetic rare diseases (GRDs), including chronic granulomatous disease, familial hemophagocytic lymphohistiocytosis, and congenital neutropenia, often require hematopoietic stem cell transplantation (HSCT) as the only curative option. Conventional myeloablative regimens are associated with considerable toxicity, whereas reduced‐intensity regimens carry an increased risk of graft failure. To address the narrow therapeutic window of busulfan, we developed a pharmacokinetic‐guided dosing strategy and evaluated it in a prospective study. Methods Children with GRDs undergoing HSCT received a conditioning regimen comprising fludarabine 40 mg/m 2 (days −8 to −4), anti‐thymocyte globulin 2.5 mg/kg (days −4 to −2), and once‐daily busulfan (days −9 to −6), with intensive pharmacokinetic monitoring and dose adjustments to achieve target exposure. Results Twenty patients with GRDs (median age, 3.6 years) received HSCT with a targeted busulfan‐based myeloablative regimen. No engraftment failure occurred. Cumulative incidences of Grade II–IV and Grade III–IV acute graft‐versus‐host disease and moderate‐to‐severe chronic graft‐versus‐host disease were 25%, 5%, and 23%, respectively. Ten‐year overall survival, event‐free survival, and transplant‐related mortality rates were 90%, 90%, and 5%, respectively. Conclusions Pharmacokinetic‐guided busulfan–fludarabine conditioning achieved reliable engraftment with acceptable toxicity in children with GRDs, supporting its use as a safe, effective HSCT conditioning strategy in vulnerable populations.