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Bone Marrow Transplantation (2011) 46, 125–131 & 2011 Macmillan Publishers Limited All rights reserved 0268-3369/11

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ORIGINAL ARTICLE

Risk of hepatitis B surface antigen seroreversion after allogeneic hematopoietic SCT M Vigano`1,7, C Vener2,7, P Lampertico1, C Annaloro2, C Pichoud3,4,5, F Zoulim3,4,5, F Facchetti1, F Poli6, M Scalamogna6, G Lambertenghi Deliliers2 and M Colombo1 1 First Division of Gastroenterology, Department of Medicine, A M and A Migliavacca Center for Liver Disease, Fondazione IRCCS Ca0 Grande Ospedale Maggiore Policlinico, Universita` di Milano, Milan, Italy; 2Hematology I—Bone Marrow Transplantation Unit, Fondazione IRCCS Ca0 Grande Ospedale Maggiore Policlinico, Universita` di Milano, Milan, Italy; 3 INSERM, U871, Lyon, France; 4Universite´ Lyon 1, Lyon, France; 5Hospices Civils de Lyon, Hoˆtel Dieu, Service d’He´patologie et de Gastroente´rologie, Lyon, France and 6Organ and Tissue Transplantation and Immunology, Fondazione IRCCS Ca0 Grande Ospedale Maggiore Policlinico, Universita` di Milano, Milan, Italy

Allogeneic hematopoietic SCT (HSCT) increases the risk of hepatitis B virus (HBV) reactivation in hepatitis B surface antigen (HBsAg) carriers but the incidence, risk factors and course of HBV reactivation after HSCT in HBsAg-negative/anti-hepatitis B core antigen (antiHBc)-positive recipients are not well known. A total of 50 HBsAg-negative/anti-HBc-positive HSCT recipients with onco-hematological diseases, underwent sequential clinical and laboratory examinations, including serum HBsAg, during follow-up. Serum HBV DNA collected at HSCT was retrospectively amplified by a sensitive PCR assay. During 17 months of follow-up, six (12%) patients had seroreverted to HBsAg, 7–32 months after HSCT, with 1- and 5-year cumulative rates of 13 and 22%. HBsAg seroreversion was associated with serum HBeAg higher than 8 log10 copies per ml HBV DNA and a 1.5 to 36 fold increase of serum alanine aminotransferase leading to HBeAg-positive chronic hepatitis B in all patients. Patients with chronic onco-hematological disease and long-lasting immunosuppression following HSCT had a higher risk of HBsAg seroreversion independently of serum HBV DNA levels at HSCT. HBsAg-negative/antiHBc-positive HSCT recipients with chronic onco-hematological disease carry a significant risk of HBsAg seroreversion and HBeAg-positive chronic hepatitis B, independently of serum levels of HBV DNA at transplantation. Bone Marrow Transplantation (2011) 46, 125–131; doi:10.1038/bmt.2010.70; published online 12 April 2010

Correspondence: Dr M Vigano`, First Division of Gastroenterology, Department of Medicine, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, University of Milan, Via F Sforza 35, 20122 Milan, Italy. E-mail: [email protected] 7 These authors contributed equally to this work. Received 24 September 2009; revised 20 January 2010; accepted 26 January 2010; published online 12 April 2010

Keywords: stem cells; BMT; HBsAg; HBV DNA; immunosuppression

Introduction Hematopoietic SCT (HSCT) has become the standard of care for selected patients with severe hematological disorders, including malignancies, severe aplastic anemia and genetic diseases.1 HSCT recipients with serum hepatitis B surface antigen (HBsAg) are at significant risk of hepatitis B virus (HBV) reactivation after anticancer chemotherapy and immunosuppressive regimens, therefore requiring either prophylaxis or treatment with antiviral therapy.2–10 HBV reactivation is also possible in HSCT recipients with potential occult HBV infection (that is, HBsAg-negative/anti-hepatitis B core antigen (anti-HBc)positive). Characteristically, these patients have episomal HBV genomes either in the liver cells or in extrahepatic sites like lymph nodes10 and ongoing low-level transcription and replication of HBV poses the risk of reactivation upon intense immunosuppression with cytotoxic drugs.11,12 Although HBV reactivation has been reported in 11–86% of HSCT recipients with potential occult infection, mainly those receiving stem cells from an anti-hepatitis B surface antigen (anti-HBs)-negative donor, with baseline anti-HBs o10 mIU/mL or requiring tapering or withdrawal of immunosuppressive therapy to treat GVHD,13–19 the clinical consequences of this complication are poorly known and clinical practice guidelines for preventing or treating this complication of HSCT are not well defined.8–10 In fact, due to limited sample size, retrospective design and short follow-up of the published studies,13–18 together with the lack of universal HBV DNA assessment by sensitive PCR assay at the time of HSCT, clinically sound predictors of HBV reactivation in HSCT recipients for targeted antiHBV prophylaxis were not identified.

HBV reactivation in anti-HBc patients after HSCT M Vigano` et al

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To gain insights, we evaluated the incidence, clinical impact and risk factors of HBV reactivation in 50 HBsAgnegative/anti-HBc-positive recipients who were followed up for 17 months after HSCT.

Materials and methods Patients A total of 231 consecutive onco-hematological patients underwent allogeneic HSCT at Hematology-Bone Marrow Transplantation Unit, Fondazione IRCCS Ca0 Grande Ospedale Maggiore, Policlinico, Mangiagalli e Regina Elena, Milan, from May 1995 to May 2005. At time of HSCT complete serological screening for HBV (HBsAg, anti-HBs, anti-HBc, hepatitis B envelope antigen (HBeAg) and antihepatitis B envelope antigen (anti-HBe)) in donor/recipient was available in 207 (90%) patients. Fifty (24%) HBsAgnegative/anti-HBc-positive patients who did not receive any specific anti-HBV prophylactic treatment before and after transplantation were included in this study. Baseline demographic and clinical characteristics of the patients included in the study are described in Table 1. None of the patients tested positive for antibody to human immunodeficiency virus or hepatitis C virus. A total of 26 patients underwent HSCT for acute onco-hematological disease such as myeloid leukemia (n ¼ 15), advanced myelodysplastic syndrome (n ¼ 3), ALL (n ¼ 4), high-grade non-Hodgkin’s lymphoma (n ¼ 4) and 24 for chronic oncohematological disease such as chronic myeloid leukemia

Table 1 Baseline demographic and clinical characteristics of the 50 HSCT recipients enrolled in the study Males Age (years)a Chronic onco-hematological disease

35 (70%) 46 (17–61) 24 (48%)

Allogeneic HSCT conditioning regimen Conventionalb Reduced intensityc

35 (70%) 15 (30%)

Stem cell source BM Peripheral blood

21 (42%) 29 (58%)

Immunotherapy pre-HSCTd

5 (10%)

Type of donor HLA-identical sibling Related mismatch Matched unrelated

45 (90%) 2 (4%) 3 (6%)

GVHD prophylaxis CY+MTX CY+Mofetil mycophenolate

40 (80%) 10 (20%)

Abbreviation: HSCT ¼ hematopoietic SCT. a Median (range). b 30 patients were conditioned with CY and TBI, 5 were conditioned with BU and Cy. c 7 patients were conditioned with fludarabine (Flu) and TBI, 8 were conditioned with CY and Flu d Rituximab (n ¼ 1), alemtuzumab (n ¼ 1), rituximab+alemtuzumab (n ¼ 3). Bone Marrow Transplantation

(n ¼ 8), chronic lymphocytic leukemia (n ¼ 9), low-grade non-Hodgkin’s lymphoma (n ¼ 4) and multiple myeloma (n ¼ 3). Pre-HSCT immunotherapy was rituximab (n ¼ 1), alemtuzumab (n ¼ 1) and rituximab and alemtuzumab (n ¼ 3). The myeloablative conditioning regimen consisted of TBI together with chemotherapy in 37 cases and chemotherapy only in the remaining 13 cases. GVHD prophylaxis included standard-dose CyA/MTX in 40 cases, and CyA/ mofetil mycophenolate in 10 cases. Acute GVHD (aGVHD) was diagnosed and graded according to Seattle guidelines modified by Armitage.20 Chronic GVHD (cGVHD) was graded according to Akpek et al.21 No post transplant immunotherapy was planned in any of the patients affected by lymphoproliferative disorders. All patients were followed up with clinical and laboratory examinations, including HBsAg, at weekly intervals for the first 2 months after HSCT; monthly, for the first year and every 6 months thereafter until the time of last analysis (December 2008) or death. HBsAg was tested during follow-up in all patients as ‘per protocol’ procedure. At each follow-up visit the clinical status of patients was recorded and blood was tested for liver biochemistry.

Donors All donors had been screened for serum HBsAg, anti-HBs and anti-HBc at the time of HSCT; all were HBsAg seronegative, 3 were anti-HBs positive and 13 were antiHBs and anti-HBc positive. Forty-five patients received hematopoietic stem cell (HSC) from HLA-identical siblings, two from a related mismatch donor and three from a matched unrelated donor. The source of the allogeneic HSCT was unmanipulated BM in 21 cases and unmanipulated PBSCs in 29 cases. Serum assays Serum aspartate aminotransferase and alanine aminotransferase (ALT) were measured by standard laboratory procedures. HBV markers (HBsAg, anti-HBs, anti-HBc, HBeAg and anti-HBe) were screened for in all donors and recipients using microparticle enzyme immunoassay (AXSYM; Abbott Laboratories, North Chicago, IL, USA). Serum HBV DNA after HBsAg seroreversion was detected by a commercial signal amplification assay (Versant 3.0, Bayer Corporation, Tarrytown, NJ, USA), with a low limit of quantification of 3.3 log10 copies per ml. In case of more than 1log copies per ml rebound of HBV DNA compared to on treatment nadir in lamivudinetreated patients, mutations in the HBV polymerase region were determined using a linear probe assay (INNO-LiPA HBV DR; Innogenetics NV, Ghent, Belgium).22 Pre-HSCT blood samples, stored under controlled conditions at 80 1C, were retrospectively evaluated for HBV DNA by a very sensitive PCR-based assay. DNA was isolated from 7 ml of whole blood by using the commercially QIAamp DNA blood Midi/Maxi Kit (Qiagen GmbH, Hilder, Germany), according to the manufacturer’s instructions. Finally, DNA was eluted in 1 ml of buffer AE and stored at 20 1C if not directly applied to PCR.


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A sequence of the HBV polymerase gene corresponding to the RT domain was amplified by PCR. The RT region was amplified on 5 ml HBV extracted DNA by the Expand High Fidelity Assay (Roche Applied Science, Mannheim, Germany) in 50 ml of mix containing buffer 10 with 1.5 mM MgCl2, 200 mM dNTPs, 2 U Taq/Tgo DNA polymerase mix and 1 mM of primers. The PCR reaction was performed with primer pair p1 50 -CCTGCTGGTGGCTCCAGTTC-30 (nucleotide position 55–77) and p2 50 -GGTTGCGTCAGC AAACACTTG-30 (nucleotide position 1197–1178) for 45 cycles, each cycle including denaturation for 30 s at 94 1C, annealing for 40 s at 50 1C and extension at 72 1C for 90 s. A second round of PCR amplification was performed with primer pair p3 50 -CCTCACAATACCGCAGAGTCTAG AC-30 (nucleotide position 230–254) and p4 50 -AAAGCCC AAAAGACCCACAAT-30 (nucleotide position 1017–997). The second round of PCR amplification was performed for 40 cycles, each cycle including 30 s denaturation at 94 1C, annealing for 30 s at 50 1C and extension at 72 1C for 60 s. PCR products were analyzed after gel electrophoresis by Southern blot hybridization: 15 ml of PCR products were migrated on a 1.5% agarose gel, blotted on Hybond N þ nylon membrane (GE Healthcare), hybridized with a 32P-labeled HBV probe (with a specific activity 5 108 c.p.m. per mg) and were subjected to autoradiography. The estimated limit of detection of the assay is 102 copies per ml. The real-time PCR assay was also performed with the real-time PCR Bio-Rad iCycler/MyiQ apparatus (Bio-Rad Laboratories, Hercules, CA, USA) with the amplification of 160 bp domain in the RT domain, with 40 amplification using 5 ml of a 1/10 dilution of extracted nucleic acid. Samples were tested in duplicate. The calibration range of the assay was 101 to 103 copies per ml.

%Patients with HBsAg seroreversion

End points The primary end point of study was the rate of HBsAg seroreversion, defined as reappearance of HBsAg in serum. Secondary end points were (1) acute liver failure, defined as jaundice, coagulopathy and encephalopathy; (2) chronic

hepatitis B, defined as the persistence of serum HBsAg for at least 6 months in the presence of persistently or intermittently HBV DNA 4105 copies per ml and ALT more than the upper limit of normal; (3) patients’ survival, calculated as the time from HSCT to death.

Statistical analysis Data were expressed as counts and percentages for qualitative variables and as median and range for discrete variables. Fisher’s exact test and Wilcoxon’s rank-sum test were used to evaluate differences in the distribution of quantitative and qualitative variables, respectively. The probability of seroreversion was assessed by the Kaplan– Meier method and the log-rank test was used to compare different groups. All P-values were two tailed and the level of 0.05 was considered statistically significant. Statistical analysis was performed with STATA (Stata Statistical Software, release 7.0.; Stata Corporation, Collage Station, TX, USA).

Results During a median follow-up of 17 months (range: 0–128), six (12%) patients showed HBsAg seroreversion after a median of 12 months (range: 7–32) from HSCT, with a 1- and 5-year cumulative rate of 13 and 22%, respectively (Figure 1). HBsAg seroreversion occurred either during tapering of immunosuppressive therapy (n ¼ 4 patients) or 4 and 8 months after the withdrawal of the immunosuppressive regimen (n ¼ 2 patients). None of these patients had the onco-hematological disease recurring before seroreversion; none of them had received post transplant immunotherapy. Seroreversion was associated with serum HBeAg, HBV DNA more than 8log10 copies per ml and a 1.5- to 36-fold (median 4) ALT increase, two patients showing acute icteric hepatitis B but no acute liver failure. Serum HBsAg and HBeAg remained detectable for more than 6 months in all patients leading to HBeAg-positive

100

80 Acute vs chronic onco-hematologic disease: p=0.02 60 Chronic onco-hematologic disease

40

All patients

20

Acute onco-hematologic disease

0

Patients still at risk

0

6

24

30

36

42

48

54

24

17

15

12

11

10

8

7

5

5

4

50

34

28

21

20

19

17

16

13

13

11

26

17

13

9

9

9

9

9

8

8

7

12

18

60 Months

Figure 1 Five-year cumulative risk of hepatitis B surface antigen (HBsAg) seroreversion in 50 HBsAg-negative/anti-HBc-positive patients following HSCT and according to chronic (n ¼ 24) or acute (n ¼ 26) onco-hematological disease. Bone Marrow Transplantation


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Detection of circulating HBV DNA at HSCT A frozen blood sample collected at the time of HSCT was available from 33 patients including the 6 who showed HBsAg seroreversion. Low levels of HBV DNA were identified by nested PCR and confirmed by Southern blot analysis in one patient (3%) only. This patient, who underwent HSCT for non-Hodgkin’s lymphoma, was treated with immunosuppressive therapy for 5 months only as he did not develop cGVHD, and remained HBsAg seronegative throughout the follow-up.

chronic hepatitis B with high levels of serum HBV DNA (48log10 copies per ml). All patients had genotype D of HBV. One patient spontaneously seroconverted to anti-HBe 18 months after HBsAg seroreversion, subsequently clearing HBsAg and developing high anti-HBs titers. In three patients, ALT spontaneously normalized 3, 8 and 11 months after HBsAg seroreversion, but HBeAg remained positive with high levels of serum HBV DNA during the 64 months (range: 20–88) of follow-up. The two remaining patients maintained more than fivefold ALT levels for more than 12 months after HBsAg seroreversion, requiring therapy with lamivudine 100 mg daily, which led to persistently undetectable HBV DNA levels and normal ALT values in one patient and development of drug resistance at month 12 in the other. Following add-on therapy with adefovir dipivoxil a virological and biochemical response was achieved after 8 months of combination therapy. Among the six patients with HBsAg seroreversion, three underwent a liver biopsy shortly after the diagnosis of chronic hepatitis B; two patients showed a chronic active hepatitis B with mild (one case) and moderate liver fibrosis (one case) without evidence of GVHD but one additional patient had evidence of both mild HBV-related inflammation and minimal colangiopathy suggesting a GVHD. None of the six patients with HBsAg seroreversion had either liver-related complications or died during 58 months of follow-up whereas 29 of 44 HBsAg seronegative patients died during 14 months of follow-up due to hematological disease (n ¼ 7), sepsis (n ¼ 10), GVHD (n ¼ 9), venoocclusive disease (n ¼ 3). Ten patients died because of liver-unrelated diseases within 100 days from HSCT and none seroreverted to HBV.

Predictors of HBsAg seroreversion HBsAg seroreversion occurred in 6 of the 24 (25%) patients with chronic onco-hematological disease in contrast to none of the 26 with acute onco-hematological disease (5-year cumulative rate: 38 vs 0%, P ¼ 0.02) (Figure 1). Duration of immunosuppressive therapy for cGVHD, rather than the occurrence of cGVHD per se, was also associated with increased risk of HBsAg seroreversion. Immunosuppression lasted 15 (7–32) months in the six patients with HBsAg seroreversion compared with 5 (0–23) months in those without HBsAg seroreversion (P ¼ 0.004). Pretransplant anti-HBs o10 mIU/mL in the donor and recipients were not associated with an increased risk of HBsAg seroreversion (Table 2).

Discussion This study clearly indicates that among HBsAg-negative/ anti-HBc seropositive HSCT recipients, those with chronic onco-hematological disease are at high risk of HBV reactivation resulting in HBeAg-positive chronic hepatitis

Table 2 Demographic and clinical characteristics recorded at baseline or during follow-up in the 50 enrolled patients, according to the HBsAg seroreversion HBsAg seroreversion

Features

P

Yes Numbers Age (years)a Men Chronic onco-hematological diseaseb Disease durationa Pre-HSCT chemotherapy Immunotherapy pre-HSCTc Conventional allogeneic HSCT HLA-identical sibling Pre-HSCT anti-HBs o10 mIU/mL in the donor Pre-HSCT anti-HBs o10 mIU/mL in the recipient Acute GVHD Hepatic acute GVHD Chronic GVHD Hepatic chronic GVHD Steroids treatment for GVHD Duration of immunosuppression (months)a Follow-up (months)a a

43 5 6 26 4 1 3 6 5 2 2 2 4 3 4 15 58

6 (32–56) (83%) (100%) (4–145) (67%) (17%) (50%) (100%) (83%) (33%) (33%) (33%) (67%) (50%) ( 67%) (7–32) (31–113)

No 46 30 18 13 41 4 32 39 29 4 22 16 18 8 22 5 14

44 (17–61) (68%) (41%) (2–216) (93%) (9%) (73%) (89%) (66%) (9%) (50%) (36%) (41%) (18%) (50%) (0–23) (0–128)

Median (range). The 6 patients with HBsAg seroreversion underwent HSCT for myeloid leukemia (n ¼ 2), CLL (n ¼ 2) and multiple myeloma (n ¼ 2). c Rituximab and/or alemtuzumab. b

Bone Marrow Transplantation

— NS NS o0.01 NS NS NS NS NS NS NS NS NS NS NS NS o0.01 o0.05


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B. Previous reports, indeed, showed the occurrence of HBsAg seroreversion in HSCT recipients with serum markers of potential occult HBV infection who did not receive preemptive antiviral therapy, however not accurately identifying the incidence rates and predictors of HBV reactivation.13–18 In these studies, in fact, a wide range of HBsAg seroreversion rate was reported in the face of a few patients included, the retrospective design of the study, the short follow-up and the different immunosuppressive regimens. Importantly, those studies reported different rates of GVHD and surveillance for HBV reactivation was restricted to patients with abnormal liver chemistries, only. A notable exception is the recently published paper by Hammond et al.19 who reported that 20% of anti-HBcpositive patients seroreverted to HBsAg, with recipients circulating pretransplant anti-HBs levels o10 mIU/mL or experiencing an extensive GVHD being significantly more likely to develop HBV reactivation. Our study stands out for having included a large cohort of patients under careful surveillance at 6-month intervals with search for serum HBsAg, independently of ALT activity. Different baseline clinical features such as the proportion of matched unrelated donors (55 vs 10%) and of extensive cGVHD (39 vs 10%) may account for the higher HBsAg seroreversion rates reported by Hammond et al. (20%) compared to our study (12%). We found that HSCT patients with anti-HBc were at risk of HBsAg seroreversion, depending on type of oncohematological disease and duration of immunosuppression for GVHD, not for GVHD per se. Indeed, duration of chemotherapy regimens before HSCT was significantly longer in patients with chronic onco-hematological disease compared with those with acute diseases (27 vs 8 months, Po0.001) and post-HSCT immunosuppression lasted for 10 months in the former and 5 months in the latter group (P ¼ 0.10). Not surprisingly, a prolonged impairment of immune-mediated control of intra-hepatic HBV after extensive immunosuppression led to reactivation of potential occult infection with HBsAg seroreversion, as previously described.10,11 Our findings are at variance with previous studies that identified an association between HBsAg seroreversion and HSCT from anti-HBs-negative donors,13,17 low pretransplant anti-HBs titers in the recipients16,19 or development of cGVHD.14,19,23–26 One practical approach, therefore, to improve the outcome of HSCT patients, could be the identification of low-level replication of HBV in recipients with potential occult HBV infection and to evaluate whether these findings correlate with a higher risk of reactivation. The search for serum HBV DNA by sensitive assays may be a poor option in immunocompetent patients with potential occult HBV infection as only a minority (18%) of such patients carry detectable HBV genomic sequences in the blood.11 Conversely, the prevalence of serum HBV DNA in immunocompromised patients in the setting of HSCT and its predictive value in the identification of patients with HBsAg seroreversion are still undefined. The only study evaluating this issue provided inconclusive results, having identified low levels of serum HBV DNA at time of HSCT in three of six recipients who subsequently had HBsAg seroreversion.18 In our study, the application of highly

sensitive and specific assay to detect serum HBV DNA at the time of HSCT failed to predict seroreversion to HBsAg, as only 3% of patients circulated low levels of HBV DNA and did not develop HBsAg seroreversion. We acknowledge that detection of HBV DNA in liver tissue cores obtained with a percutaneous liver biopsy is still the gold standard in patients with potential occult HBV infection, but it is limited by the risks and costs inherent with such an invasive procedure, as a liver biopsy.10 In HSCT recipients, HBsAg seroreversion needs to be distinguished from de novo infection with HBV acquired through infected HSC or donated blood, though the latter events are unlikely, considering the safety records of the donated blood in Italy.27 In our cohort the time lag between HSCT or blood transfusion and the first HBsAg seroreversion was 7 months, longer than the maximum incubation period of 6 months predictive for de novo infection with HBV. HBsAg seroreversion may have potentially important clinical consequences, as reconstitution of host immunity following tapering or interruption of cytotoxic therapy may lead to a rapid immune-mediated destruction of infected hepatocytes with subsequent liver failure. Overall, a sizable proportion of patients with HBsAg seroreversion linked to immunosuppression, ultimately developed fulminant hepatitis or hepatic decompensation or progressive chronic hepatitis B.13–18,23–26,28–35 In our study, no patient with HBV reactivation experienced acute liver failure, but two had acute icteric hepatitis B and all become HBeAg-positive chronic carriers. Though recommended, anti-HBV treatment of these patients is challenged by the high viral load, the immunosuppression status, the presence of comorbidities and the high risk of drug resistance in the long term. At present, there is no consensus on which anti-HBV strategy might prevent this difficult-to-treat clinical scenario.8–10,36,37 One option is to treat patients with antiviral therapy at the time of hepatitis B onset or start anti-HBV prophylaxis at the time of HBV DNA flare or HBsAg seroreversion (targeted prophylaxis) or at HSCT (universal prophylaxis). The first approach may not suffice to attenuate liver injury or acute liver failure, whereas it may not prevent development of chronic hepatitis B, that may interfere with hematological therapies while impacting on patient survival.9 Targeted prophylaxis relies on careful and regular monitoring of serum HBsAg and HBV DNA with sensitive assays and start of anti-HBV treatment before the onset of liver injury.8,9 Another option is universal prophylaxis of all HBsAg-negative/anti-HBc-positive HSCT recipients to prevent the occurrence of liver disease associated to HBV DNA breakthrough and HBsAg seroreversion. This latter strategy could be a cost-effective approach, considering the current expanded use of matched unrelated donors and of pretransplant and post transplant immunotherapy that may increase the HBsAg seroreversion rates, although its long-term efficacy and safety is still not proven. In conclusion, HBsAg-negative/anti-HBc-positive HSCT recipients with chronic onco-hematological disease carry a significant risk of HBsAg seroreversion and HBeAg-positive chronic hepatitis B. Whether universal or targeted anti-HBV prophylaxis should be considered as the most cost-effective strategy to prevent morbidity and mortality related to HBV Bone Marrow Transplantation


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reactivation in these patients needs to be tested in prospective clinical trials.

Conflict of interest Massimo Colombo—Consulting: Bristol-Meyers-Squibb, Schering-Plough, Roche, Novartis, Gilead, Vertex. Grant and research support: Bristol-Meyers-Squibb, ScheringPlough, Roche, Novartis, Gilead, Vertex; Advisory committees: Bristol-Meyers-Squibb, Schering-Plough, Roche, Novartis, Gilead, Vertex. Speaking and teaching: BristolMeyers-Squibb, Schering-Plough, Roche, Novartis, Gilead, Vertex Pietro Lampertico—Advisory board/speaker bureau: Bristol-Meyers-Squibb, Roche, Novartis, Gilead, GSK. The other authors have no conflict of interest.

Acknowledgements We thank Miss Caterina M Puricelli for her expert secretarial assistance.

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