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Steroid‐refractory acute graft‐versus‐host disease graded III‐IV in pediatric patients. A mono‐institutional experience with a long‐term follow‐up

aGvHD remains a major obstacle to successful HSCT. We report our experience on steroid‐refractory aGvHD III and IV from 1989 to 2017. Ninety patients with aGvHD III or IV were stratified according to the HSCT year: 1989‐1998, 1999‐2007, and 2008‐2017 and to aGvHD extension (GvHD III vs IV) and finally the probability of OS, RI, and TRM was calculated accordingly. aGvHD III patients had a substantial improvement over time: day 100 OS raised from 64% (95% CI 39‐89) in the first cohort to 100% in the latest (P = .022), and it was mainly due to a reduction of TRM (it was 28% [95% CI 12‐65] in the first cohort to 0% in the latest (P = .01). The aGvHD IV patients did not present a significant improvement. Day 100 OS was 42% (95% CI 16‐68) in the first group and 54% (95% CI 25‐83) in the year 2008‐2017 (P = NS), and the day‐100 TRM was very similar (it was 57% [95% CI 36‐90] in the first cohort and 45% [95% CI 23‐89] in the latest (P = NS). We report significant improvements in OS and TRM in patients diagnosed with grade III aGvHD. Patients with the most severe aGvHD appear to have no or fewer benefits on long‐term outcomes.