Département d’hématologie pédiatrique, hôpital San-Camillo, Rome, Service d’hématologie, CHU Henri-Mondor, 94000 Créteil
Although the risk of acquisition of hepatitis B or hepatitis C virus through blood products has considerably reduced since the last decade, some infected patients are candidates to stem cell transplantation. Others may have no alternative than an infected donor. In all these cases, recipients of transplant are prone to short and long term liver complications. The evolution of liver tests under chemotherapy before transplant may give useful information to anticipate on the risk of hepatitis reactivation after transplant, both for HBV and HCV. More than sixty percent of the patients who are HBsAg-positive before transplant reactivate after transplant, and 3 % develop acute severe liver failure. Because both viral replication and immune reconstitution are the key factors for reactivation, it is crucial to closely follow liver test and viral load during the first months of transplant, and to pay a special attention in slowly tapering the immunesuppression in these patients. Lamivudine reduces HBV viremia, but favors the emergence of HBV polymerase gene mutants and should be individually discussed. Both in case of HBV or HCV hepatitis reactivation with ALT ≥ 10N concomittantly to an increase in viral load at time of immune reconsitution, steroids should be given. In case there is no alternative than a HBV or HCV positive geno-identical donor, the risk of viral hepatitis, including acute liver failure and late complications, should be balanced with the benefit of transplant in a given situation. Because these situations are not so unusual, the Infectious Diseases and Late Effects Working Parties of the European Group for Blood and Marrow Transplantation have elaborated a first proposal of guidelines for the management of this special population.