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This study was designed to investigate if RBC alloimmunization before hematopoietic cell transplant (HCT) was associated with post\u2010HCT outcomes and transfusion support using the multicenter Sickle cell Transplant Advocacy and Research (STAR) retrospective registry. From a cohort of 229 pediatric patients with SCD who underwent human leukocyte antigen (HLA)\u2010matched related donor HCT with myeloablative or reduced intensity conditioning, 40 patients (17%) were RBC alloimmunized pre\u2010HCT. The RBC alloimmunized group had a significantly higher incidence of grade III\u2010IV acute graft\u2010versus\u2010host disease (GVHD) (15% vs. 3.7%,\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.013), which remained significant (OR 4.22, 95% CI, 1.19, 14.3;\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.027) when controlling for pre\u2010HCT RBC transfusion burden and conditioning intensity. Graft failure occurred in 10% of RBC alloimmunized patients compared with 2.6% of non\u2010alloimmunized patients,\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.052. Patients with RBC alloimmunization had lower 5\u2010year severe GVHD\u2010free, rejection\u2010free survival (69% vs. 88%,\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.004), which remained significant when controlling for age. Post\u2010HCT patients received a median 3 RBC units (IQR 2, 6) and 11 platelet transfusions (IQR 7, 19). Pre\u2010HCT RBC alloimmunization was associated with a greater requirement for post\u2010HCT platelet transfusions, but not post\u2010HCT RBC units transfused. We postulate that the observed associations of pre\u2010HCT RBC alloimmunization with severe acute GVHD and post\u2010HCT platelet transfusion burden are due to inherent immunologic characteristics that render patients at increased risk of developing multiple immune\u2010mediated complications.\n                  <\/jats:p>","DOI":"10.1002\/ajh.70200","type":"journal-article","created":{"date-parts":[[2026,1,12]],"date-time":"2026-01-12T14:53:28Z","timestamp":1768229608000},"page":"756-767","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["<scp>RBC<\/scp>\n                    Alloimmunization Impacts Pediatric Sickle Cell Disease Transplant Outcomes and Transfusion Burden: A\n                    <scp>STAR<\/scp>\n                    Registry Report"],"prefix":"10.1002","volume":"101","author":[{"given":"Zaina","family":"Inam","sequence":"first","affiliation":[{"name":"Division of Hematology Children's National Hospital  Washington DC USA"},{"name":"George Washington University School of Medicine and Health Sciences  Washington DC USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth","family":"Stenger","sequence":"additional","affiliation":[{"name":"Aflac Cancer and Blood Disorders Center Children's Healthcare of Atlanta\/Emory University  Atlanta Georgia USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tami D.","family":"John","sequence":"additional","affiliation":[{"name":"Division of Pediatric Hematology, Oncology, Stem Cell and Regenerative Medicine Stanford University  Palo Alto California USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katie","family":"Liu","sequence":"additional","affiliation":[{"name":"Pediatric Biostatics Core, Department of Pediatrics Emory School of Medicine  Atlanta Georgia USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Scott","family":"Gillespie","sequence":"additional","affiliation":[{"name":"Pediatric Biostatics Core, Department of Pediatrics Emory School of Medicine  Atlanta Georgia USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rikin","family":"Shah","sequence":"additional","affiliation":[{"name":"Orlando Health \u2013 Arnold Palmer Hospital for Children  Orlando Florida USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Deepakbabu","family":"Chellapandian","sequence":"additional","affiliation":[{"name":"Cancer and Blood Disorders Institute Johns Hopkins All Children's Hospital  St Petersburg Florida USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Monica","family":"Bhatia","sequence":"additional","affiliation":[{"name":"Division of Pediatric Hematology\/Oncology\/Stem Cell Transplantation Columbia University Medical Center  New York New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sonali","family":"Chaudhury","sequence":"additional","affiliation":[{"name":"Division of Pediatric Hematology Oncology\/Bone Marrow Transplantation Ann and Robert H Lurie Children's Hospital of Chicago  Chicago Illinois USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael J.","family":"Eckrich","sequence":"additional","affiliation":[{"name":"Pediatrics Hematology, Oncology, Transplant and Cellular Therapy University of Wisconsin School of Medicine and Public Health  Madison Wisconsin USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gregory M. T.","family":"Guilcher","sequence":"additional","affiliation":[{"name":"Section of Pediatric Hematology, Oncology and BMT University of Calgary Cumming School of Medicine, Alberta Children's Hospital  Calgary Alberta Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7928-3132","authenticated-orcid":false,"given":"Jeanne E.","family":"Hendrickson","sequence":"additional","affiliation":[{"name":"Department of Pathology and Laboratory Medicine Emory University  Atlanta Georgia USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8933-0046","authenticated-orcid":false,"given":"Monica L.","family":"Hulbert","sequence":"additional","affiliation":[{"name":"Division of Hematology\/Oncology, Boston Children's Hospital Department of Pediatric Oncology, Dana\u2010Farber Cancer Institute, Harvard Medical School  Boston Massachusetts 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