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Severe hepatitis C reactivation as an early complication of hematopoietic cell transplantation

Bone Marrow Transplantation volume 52, pages 138–140 (2017)Cite this article

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Hepatitis C virus (HCV) infection is the most common blood-borne infection in the United States, affecting an estimated 2.7–3.9 million persons.1 Among patients with cancer, the estimated prevalence of HCV infection is up to 30%.2, 3 In cancer patients with chronic HCV infection receiving chemotherapy, exacerbation and reactivation of HCV infection are recognized as causes of liver dysfunction.4, 5, 6 Exacerbation of HCV infection is defined as a threefold or greater rise in alanine aminotransferase (ALT) level in a patient without other causes of liver dysfunction, such as malignant infiltration, certain drugs, systemic infections affecting the liver, receipt of blood transfusion within 1 month of ALT elevation or GVHD of the liver.5 Reactivation of HCV infection is defined as a rise in the HCV RNA level of at least 1 log10 IU/mL from baseline, as HCV RNA levels in chronically-infected patients may fluctuate by about 0.5 log10 IU/mL.4, 5

Cancer patients with chronic HCV infection who undergo hematopoietic cell transplant (HCT) are at high risk for accelerated progression of liver fibrosis—progression can be twice as fast as in HCV-infected patients not undergoing HCT—and death due to infectious causes and GVHD.7, 8 Currently available information suggests that compared with hepatitis B virus reactivation, HCV reactivation rarely causes significant liver-related morbidity and mortality.4, 5, 9, 10 However, little is known about the natural course or outcomes of HCV exacerbation and reactivation in HCT recipients. Recently published task force guidelines for treatment of chronic HCV infection in HCT candidates recommend completing antiviral treatment before HCT when possible.11 However, in patients who cannot delay HCT because of the risk of cancer relapse, deferring antiviral therapy until 6 months after HCT is the most common approach. At this point, most patients will have finished immunosuppressive therapy, which can cause toxic effects overlapping with those of antivirals and drug-drug interactions with antivirals.11 Immediate antiviral treatment after HCT is recommended only in patients who develop fibrosing cholestatic hepatitis or decompensated cirrhosis and in patients with HCV-related lymphoproliferative disorders.11 Whether HCV reactivation during HCT warrants urgent antiviral treatment has not been established.11

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Acknowledgements

We thank Ms. Stephanie Deming in the Department of Scientific Publications at The University of Texas MD Anderson Cancer Center for editorial assistance.

Author contributions

Study design: NTO, HAT. Treatment and observation of patients: NTO, EA-H, YLN, BB, PA, HAT. Data collection and analysis: NTO, HAT. Provision of expert opinions: NTO, EA-H, YLN, BB, PA, HAT. Manuscript writing: NTO, HAT.

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Authors and Affiliations

  1. Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA

    N T Oliver

  2. Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Y L Nieto & P Anderlini

  3. Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    B Blechacz

  4. Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    E Ariza-Heredia & H A Torres

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  1. N T Oliver
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  2. Y L Nieto
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  6. H A Torres
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Corresponding author

Correspondence to H A Torres.

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Competing interests

HAT is or has been the principal investigator for research grants from Gilead Sciences, Merck & Co., Inc., and Vertex Pharmaceuticals, with all funds paid to The University of Texas MD Anderson Cancer Center. HAT is or has been a paid scientific advisor for Gilead Sciences, Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Vertex Pharmaceuticals, Genentech, Novartis, Astellas Pharma, Pfizer Inc., and Theravance Biopharma, Inc.; the terms of these arrangements are being managed by MD Anderson Cancer Center in accordance with its conflict-of-interest policies.

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Oliver, N., Nieto, Y., Blechacz, B. et al. Severe hepatitis C reactivation as an early complication of hematopoietic cell transplantation. Bone Marrow Transplant 52, 138–140 (2017). https://doi.org/10.1038/bmt.2016.196

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