Hematopoietic stem cell transplantation for acute myeloid leukemia: Brazilian Society of Cell Therapy and Bone Marrow Transplantation Consensus

This document updates the 2023 Brazilian Society of Cell Therapy and Bone Marrow Transplantation (SBTMO) consensus on allogeneic hematopoietic stem cell transplantation (HSCT) for acute myeloid leukemia (AML), incorporating the 2022 and 2024 European LeukemiaNet (ELN) risk classifications, the 2025 ELN-DAVID measurable residual disease (MRD) recommendations, recent induction trials, and the 2025 European Society for Blood and Marrow Transplantation (EBMT) transplant indications. MRD monitoring, assessed by quantitative polymerase chain reaaction, next-generation sequencing, or multiparameter flow cytometry, now guides transplant timing alongside ELN risk category, refining decisions in intermediate-risk patients and informing pre- and post-transplant management. Allogeneic HSCT remains indicated for adverse-risk AML and second complete remission regardless of MRD status, while favorable-risk patients generally avoid transplant unless MRD persists after consolidation. For elderly patients, chronological age alone should not exclude HSCT candidacy; comprehensive geriatric assessment and alternative donor sources have expanded access, supported by Brazilian regulatory changes raising the eligibility age to 75. Conditioning strategy, graft-versus-host disease prophylaxis with post-transplant cyclophosphamide, stem cell source selection, and donor immunogenetic screening are addressed, alongside emerging post-transplant maintenance therapies for high-risk molecular subgroups. Novel cellular therapies— CAR-T and CAR-NK cells—remain investigational, limited by antigen escape and short persistence, requiring consolidation with allogeneic HSCT. This consensus provides evidence-graded recommendations to standardize transplant decisionmaking for AML across Brazilian centers, reflecting the rapidly evolving therapeutic and diagnostic landscape.