Successful Allogenic and Autologous Transplant with Concurrent Usage of Direct-Acting Antivirals for Hepatitis C in Children with Hematological Malignancies

Abstract

Background Transfusion related hepatitis C(HCV) is rare in the west, in the developing world, it remains a challenge. Children with hematological malignancies are especially vulnerable due to large number of blood components received. They often develop active hepatitis due to immunocompromised status and concurrent hepatic insults from chemotherapy and iron overload. Stem cell transplant(SCT) further increases hepatic risk due to veno-occlusive disease(VOD) and hepatic graft versus host disease(GVHD). Direct acting antivirals(DAA) have revolutionized treatment of HCV. DAAs are currently not approved for children Results We describe allogenic and autologous SCT in two children while on DAA. An 8 year old girl with relapsed AML and baseline viral load(VL) of >10^6 IU/ml (genotype 1b) presented with transaminitis and refractory thrombocytopenia. Sofosbuvir 200mg and velpatasvir 50mg once daily were started with salvage chemotherapy(FLAG-IDA). VL was undetectable after 5 weeks when allogeneic SCT(Cy/Bu) was initiated while continuing DAAs. Neutrophils and platelet engraftment occurred at day + 11 and + 14 respectively. DAAs were continued for 3 months post SCT(until withdrawal of immunosuppression). There was no evidence of VOD or liver GVHD. A 9 year old girl with relapsed lymphoblastic lymphoma, had a baseline VL of >10^6 IU/ml with genotype1b. She was started on the same DAAs and taken for auto SCT(Cy/TBI). G-CSF and plerixafor were used for mobilization and a stem cell dose of 10 × 10^6 cells/ kg was collected. Neutrophils and platelet engraftment occurred on day +10 and day + 16 respectively. No hepatic toxicity was noted. DAAs were continued for 3 months post SCT and VL remained undetectable. Conclusion Use of DAAs is feasible during allogeneic and autologous SCT and does not interfere with mobilization or engraftment. This could decrease the risk of hepatic adverse events during SCT.