Table 7.

Consensus recommendations for HLH referral and transplantation.

S. No.	Recommendation	Grade of evidence	Level of agreement (%)
31.	HSCT is indicated for primary/genetic HLH and refractory/relapsed cases, and its early integration should be prioritized in the GCC due to the high prevalence of pathogenic HLH variants.	Moderate	100% (15/15)
32.	Referral timing should prioritize achieving disease remission or minimal active inflammation before HSCT to reduce graft failure and improve outcomes, especially in genetically predisposed populations.	Low	93% (14/15)
33.	Referral pathways should be standardized to ensure early HSCT consultation, donor search, and HLA typing, thereby minimizing delays that compromise transplant success.	Low	100% (15/15)
34.	HSCT conditioning should be individualized, balancing disease eradication and toxicity. Reduced-intensity conditioning is often preferred to reduce early transplant-related morbidity.	Moderate	93% (14/15)
35.	Adults and older patients with HLH should be evaluated for HSCT similarly to pediatric cases in appropriate clinical contexts.	Low	93% (14/15)

Level of agreement was calculated as the proportion of respondents selecting either “agree” or “somewhat agree.”.

GCC, Gulf Cooperation Council; HLA, human leukocyte antigen; HLH, hemophagocytic lymphohistiocytosis; HSCT, hematopoietic stem cell transplantation.