Association of lamivudine resistance in recurrent hepatitis B after liver transplantation with advanced hepatic fibrosis

BACKGROUND

Orthotopic liver transplantation (OLT) in patients with hepatitis B virus (HBV) infection is known to be associated with a high recurrence rate and poor prognosis. Lamivudine, a nucleoside analogue, is a potent inhibitor of HBV replication, but it is associated with a 14-39% rate of resistance.

METHODS

We report on four patients who underwent OLT for HBV infection. In all cases, the HBV infection recurred in the grafted liver and was treated with lamivudine (100 mg daily) on a compassionate-use basis. The patients were monitored closely for serum liver enzymes, hepatitis B surface antigen and HBV DNA (by hybridization). Liver biopsy was performed before and after lamivudine therapy. HBV DNA was amplified from serum for each patient and sequenced through a conserved polymerase domain, the tyrosine-methionine-aspartate-aspartate (YMDD) locus.

RESULTS

All four patients exhibited lamivudine resistance 9-20 months after initiation of the drug. In all patients with a clinically mild disease, liver histology findings (12-24 months after lamivudine therapy) showed progressive fibrosis as compared to biopsies performed before lamivudine therapy, with a significant increase (> or =2 points) in the Knodell score in three patients. Moreover, two patients exhibited worsening of the necroinflammatory process. A mutation at the YMDD motif of the HBV polymerase gene was detected in all cases.

CONCLUSIONS

Lamivudine resistance frequently occurs in patients with recurrent HBV infection after OLT and is associated with advanced hepatic fibrosis and necroinflammatory process. A combination of antiviral therapies may be necessary.

Nitric oxide metabolites in decompensated liver cirrhosis

High levels of nitric oxide are thought to be the cause of some of the complications associated with decompensated end-stage liver disease. To assess nitric oxide metabolism in cirrhotic patients, we measured the levels of nitric oxide metabolites (nitrosohemoglobin, methemoglobin, nitrate, and nitrite) in normal subjects, in patients with decompensated cirrhosis, in patients with renal failure (model for impaired NO metabolites excretion), and in patients with mononitrates-treated anginal syndrome (model for exogenous nitric oxide). When compared to controls, patients with decompensated cirrhosis exhibited elevated levels of nitrate only. A significant increase of nitrate was also noted in patients receiving exogenous nitrates, whereas patients with impaired excretion had significantly elevated levels of both nitrite and nitrate. In conclusion, nitric oxide metabolism in patients with decompensated cirrhosis is similar to that of patients receiving nitric oxide from an exogenous source. Renal impairment, whether alone or associated with cirrhosis, causes a change in nitric oxide metabolism. These findings may have clinical implications for nitrates treatment in patients with decompensated cirrhosis.

Posttransplantation lymphoproliferative disorder in liver recipients: characteristics, management, and outcome

Posttransplantation lymphoproliferative disorder (PTLD) is a well-recognized complication of organ transplantation. The aim of this study, performed over 9 years, was to examine the histopathological findings, clinical course, and outcome of patients who, having undergone orthotopic liver transplantation (OLT), developed PTLD. The sample included 7 adult liver allograft recipients (1.7%), 4 men and 3 women, with a mean age of 53 years (range, 40 to 61 years) who developed PTLD 1 to 36 months post-OLT (mean, 6 months). Four patients received either antithymocyte globulin as primary immunosuppression or OKT3 for steroid-resistant cellular rejection. Four patients had localized hepatic tumor with or without regional lymph node involvement, 2 patients had extralymphoreticular disease (head of pancreas and chest wall), and 1 patient had spleen and lymph node involvement. All tumors were B-cell lymphomas; three polymorphic and four monomorphic. Clonality was assessed by immunostaining for kappa and lambda and gene rearrangement. Monoclonality was found in 4 patients and polyclonality in 2 (1 of whom progressed to monoclonality); in 2 patients, clonality could not be determined. Immunohistochemistry findings for the presence of the Epstein-Barr virus (EBV)-determined nuclear antigen and the latent membrane protein 1 were noted in lymphoma tissue in 6 patients. Immunosuppressive therapy was decreased in all patients. Polyclonal tumors were treated with acyclovir (1 patient is in complete remission and 1 patient died), and monoclonal tumors with systemic chemotherapy (2 patients are in complete remission and 2 patients died). One patient was treated with monoclonal antibodies (CD20) but failed to respond, and 1 patient was treated with excision and is in complete remission. The mortality rate was 43%; for the remainder, median survival is 21 months (range, 10 to 42 months). We conclude that PTLD may re-present early after OLT. EBV has a special role in the pathogenesis, combined with immunosuppressive therapy. The outcome is poor, and new therapeutic approaches are needed.

Efficacy of lamivudine in patients with hepatitis B virus precore mutant infection before and after liver transplantation

OBJECTIVE

Hepatitis B virus (HBV) precore mutant infection is associated with a more severe liver disease and a poorer response to interferon. We evaluated the efficacy and tolerance of lamivudine to induce complete and sustained suppression of viral replication in seven patients infected with HBV precore mutant (HBeAg-/HBeAb+/HBV DNA+) (in three patients mutation at codon 1896 was detected by direct sequencing).

METHODS

Of the seven patients, five had decompensated HBV cirrhosis in a replicative phase and were liver transplant candidates (Group A) and two patients underwent orthotopic liver transplantation (OLT) for HBV liver cirrhosis and developed recurrent HBV infection in the grafted liver (Group B). Lamivudine 100 mg daily was administered orally for a period of 6-75 wk.

RESULTS

After 6-8 wk lamivudine therapy was well tolerated and successfully suppressed HBV replication to an undetectable serum level of HBV DNA by polymerase chain reaction in six patients. In Group A, two patients underwent successful OLT with no evidence of HBV reinfection 2-14 months later. Lamivudine was continued after OLT with no episodes of rejection. Three patients died before a suitable liver could be found (one remained serum HBV DNA+ after 6 wk of lamivudine therapy). In Group B, 9-14 months after lamivudine therapy both patients developed lamivudine resistance (increased liver enzymes, reappearance of serum HBsAg and HBV DNA [by hybridization]). In both patients liver histology had progressed and in both, mutation at codon 552 of the HBV polymerase gene was detected.

CONCLUSIONS

Lamivudine is well tolerated in patients with decompensated liver cirrhosis due to HBV precore mutant infection who are liver transplant candidates. In four patients (80%) potent suppression of viral replication was detected, allowing OLT to be performed. However, post-OLT, a resistant mutant developed under lamivudine therapy. Combination therapy with other antiviral agents should be evaluated to discourage the emergence of lamivudine-resistant mutants.

Eosinophils in acute cellular rejection in liver allografts

Eosinophils have a role in various allergic and inflammatory disease processes and participate in the process of acute rejection in solid organ allografts. Initial studies described the diagnostic value of eosinophils in kidney allograft rejection. Graft eosinophilia is a sensitive and specific marker of acute rejection in liver allografts and has been incorporated as one of the diagnostic criteria of acute rejection by the Royal Free Hospital scoring system. Blood eosinophilia also has been investigated and is a useful diagnostic marker of acute rejection in liver and kidney allografts, although studies differ in defining the day of onset of eosinophilia in relation to rejection. Eosinophils probably act through the chemokines interleukin-5 and RANTES (regulated on activation, normal T cells expressed and secreted) in the pathogenesis of acute rejection. Basic cytotoxic proteins, such as eosinophil cationic protein and major basic protein, are released by the eosinophils, and their effector role in acute rejection has been studied through the use of specific monoclonal antibodies. Successful treatment of acute rejection with corticosteroids has been associated with a decrease in graft and blood eosinophil counts. Eosinophils also act as prognostic markers of acute rejection, as shown by studies reporting that patients with elevated eosinophil counts and steroid-resistant rejection showed a worse prognosis. Further research into the effector mechanisms of eosinophils in acute rejection needs to be performed. The ability of eosinophils to distinguish those diseases with different responses to standard immunosuppression and other diseases in the context of acute rejection also needs to be studied.

Infection rates with and without T-tube splintage of common bile duct anastomosis in liver transplantation

Stenting the bile duct over a T-tube after orthotopic liver transplantation (OLT) is the preferred method of biliary reconstruction. However, because of complications associated with the use of the T-tube, we evaluated the effect of various biliary anastomoses following 100 consecutive OLT (83 records were available for long-term evaluation) and assessed the clinical outcome of abandoning routine T-tube splintage. Of 16 OLT recipients with T-tube splintage (one died immediately following OLT and was excluded from the study), 6 patients (40%) developed six episodes of septicaemia secondary to biliary and/or intra-abdominal sepsis. Four of these six patients had a biliary leak (27%). Of 57 patients with duct-to-duct anastomosis without T-tube splintage, 7 patients developed biliary leak (12.3%) and only 1 developed septicaemia (1.7%) secondary to biliary and intra-abdominal sepsis (P = 0.0002). Of 11 patients with either a gallbladder conduit or Roux loop, only 1 patient had a biliary leak (9%) and there were no septicaemic episodes. In conclusion, direct duct-to-duct anastomosis resulted in significantly less morbidity due to infection without T-tube splintage than the use of a T-tube following OLT, but there were no significant differences in leakage and stricture rates.

Infection rates with and without T-tube splintage of common bile duct anastomosis in liver transplantation

Stenting the bile duct over a T-tube after orthotopic liver transplantation (OLT) is the preferred method of biliary reconstruction. However, because of complications associated with the use of the T-tube, we evaluated the effect of various biliary anastomoses following 100 consecutive OLT (83 records were available for long-term evaluation) and assessed the clinical outcome of abandoning routine T-tube splintage. Of 16 OLT recipients with T-tube splintage (one died immediately following OLT and was excluded from the study), 6 patients (40%) developed six episodes of septicaemia secondary to biliary and/or intra-abdominal sepsis. Four of these six patients had a biliary leak (27%). Of 57 patients with duct-to-duct anastomosis without T-tube splintage, 7 patients developed biliary leak (12.3%) and only 1 developed septicaemia (1.7%) secondary to biliary and intra-abdominal sepsis (P = 0.0002). Of 11 patients with either a gallbladder conduit or Roux loop, only 1 patient had a biliary leak (9%) and there were no septicaemic episodes. In conclusion, direct duct-to-duct anastomosis resulted in significantly less morbidity due to infection without T-tube splintage than the use of a T-tube following OLT, but there were no significant differences in leakage and stricture rates.

[Living-related liver transplantation--first experiences at Rabin Medical Center]

Our experience with living-related liver transplantation is described. In 2 boys and 1 girl, aged 4-4.5 years with acute, fulminating hepatitis A, the presence of very severe jaundice (bilirubin levels > 18 mg%) associated with severe coagulopathy (INR > 10) and encephalopathy indicated the need for urgent liver transplantation. In all 3 cases the left lateral hepatic segment of a matched blood type parent was transplanted. None of the donors suffered a serious complication postoperatively and all returned to full activity in 6-16 weeks. The post-transplantation course was uneventful in 1 child, but in the other 2 there was hepatic arterial thrombosis in 1 at 1 day and in the other at 8 days post-transplantation. Early detection of arterial thrombosis by Doppler sonography permitted salvage of the 2 hepatic grafts after thrombectomy and re-anastomosis. In 1 of these 2 children an anastomotic biliary stricture was found 2 months after transplantation. It was corrected at surgery and a percutaneous stent was inserted. All 3 children are alive with normal graft function at 2, 7 and 8 months post-transplantation, respectively. This initial experience indicates that living-related liver transplantation is feasible in Israel. The technique might help to solve our severe organ shortage for children awaiting liver transplantation.

Loss of serum HBsAg after interferon-A therapy in liver transplant patients with recurrent hepatitis-B infection

Reinfection with hepatitis B virus after orthotopic liver transplantation is nearly universal in patients who have not received posttransplant immunoprophylaxis. Recurrence almost invariably leads to chronic liver disease. Interferon has been used both prophylactically and therapeutically but has not been effective. We treated 2 liver transplant patients with recurrent hepatitis B virus (HBV) infection (serum hepatitis B surface antigen [HBsAg] and HBV DNA positive on polymerase chain reaction, and positive liver biopsy result) with interferon, 3 to 6 MU three times weekly for 6 to 22 months. A full response to therapy was manifested in both patients by normalized serum alanine aminotransferase levels and the loss of serum HBsAg and HBV DNA. The effectiveness of interferon in our patients may have been related to coinfection with hepatitis D virus in the first case and the high interferon dose (6 MU, three times weekly) and long treatment period (22 months) in the second. No episodes of rejection were noted during therapy. We conclude that interferon can induce a complete response in liver transplant patients with recurrent HBV infection. Future studies should investigate the use of interferon therapy at higher doses and/or for longer periods.

[Liver allografts from donors older than 60: benefits and risks]

With limited organ resources and an increasing number of candidates for liver transplantation, the world-wide trend is towards using liver allografts from donors older than 60 years. This strategy, however, may be hazardous because of the known correlation between advanced donor age and graft dysfunction. Since January 1996, each of 5 patients received a liver allograft from a donor older than 60 years. Preservation time in these cases was shortened as much as possible and liver allografts were used only if there were no other potential risk factors for primary nonfunction. Mean cold ischemic time was significantly shorter in this donor group (7.8 hrs) than for livers from 28 younger donors (10.2 hour; p < 0.01). 3 of the 5 grafts from older donors had normal function immediately. The other 2 initially had biochemical features of preservation injury, but graft function returned to normal within the first week after transplantation. All 5 patients currently have normal graft function, with follow-up ranging from 3-8 months. There was no difference between the 5 recipients of grafts from older donors and 28 adult recipients of grafts from younger donors in extent of preservation injury and in immediate graft function. We conclude that in countries with limited organ resources, such as Israel, liver allografts from older donors can be used within defined limits and minimal preservation time.

Hypercoagulability in patients with primary biliary cirrhosis and primary sclerosing cholangitis evaluated by thrombelastography

BACKGROUND/AIMS

Patients with primary biliary cirrhosis and primary sclerosing cholangitis survive variceal bleeding better than patients with alcoholic cirrhosis and have less bleeding at liver transplantation. Recently, patients with primary biliary cirrhosis have been found to have a higher incidence of thrombosis in the portal venous tree. We hypothesized that primary biliary cirrhosis and primary sclerosing cholangitis patients may be hypercoagulable.

METHODS

We used thrombelastography, which is a simple technique for evaluating whole blood clotting and fibrinolysis, to establish if hypercoagulability was present, defined by thrombelastography values greater than 2SD over controls: r<19 mm (this reflects plasma clotting factors), maximum amplitude (ma) >60 mm, and alpha angle >43 degrees (these reflect platelets and fibrinogen levels). We evaluated 47 primary biliary cirrhosis and 21 primary sclerosing cholangitis patients, 40 with non-cholestatic cirrhosis and 40 healthy subjects as control groups with thrombelastography, full blood count, prothrombin time, partial thromboplastin time and, fibrinogen concentrations. In those with hypercoagulability we evaluated protein S, C, anti-thrombin III levels and activated protein C phenotype.

RESULTS

All three thrombelastography abnormalities present together defined hypercoagulability: these were found in 13 of 47 (28%) primary biliary cirrhosis and in nine of 21 (43%) primary sclerosing cholangitis patients independent of cirrhosis, and bilirubin concentration, but in only 2 of 40 (5%) patients with noncholestatic cirrhosis and in none of the healthy controls (p<0.03 and p<0.0002, respectively). There was no correlation between the fibrinogen concentration (which was normal in all patients) or platelet count and the thrombelastography parameters. Only six of the 22 hypercoagulable patients had lower than normal values of protein S, C or antithrombin III. Activated protein C phenotype was normal in all.

CONCLUSIONS

This diffference between biliary and parenchymal liver disease may have clinical implications, which need to be defined.

Beneficial effect of lamivudine in recurrent hepatitis B after liver transplantation

Orthotopic liver transplantation (OLT) in patients infected with hepatitis B virus (HBV) is known to be associated with a high recurrence rate and poor prognosis. Interferon treatment in these patients offers little benefit and may lead to further complications. Lamivudine, the (-)enantiomer of 3'-thiacytidine, a 2'3'-dideoxynucleoside, is known to be a potent inhibitor of HBV replication in patients with chronic HBV infection. Three HBV-positive OLT patients were administrated lamivudine, 100 mg x 1 orally, for a period of at least 20 weeks, in an open, compassionate-use basis. All three patients were HBV DNA-negative before OLT. HBV reinfection occurred at a median time of 7 months (range, 6-9 months) after OLT, in spite of adequate immunoprophylaxis. All three patients had high serum transaminase levels (alanine aminotransferase [ALT], 103-324 U/L) and histologic evidence of recurrent HBV infection of the grafted liver, and HBV DNA was evident in the sera of all of them. Six weeks after lamivudine treatment, HBV DNA disappeared from the serum of all patients (detected by hybridization); by the 10th week, HBV DNA was also negative by polymerase chain reaction in two out of three patients. Interestingly, the one patient who was HBV DNA positive by polymerase chain reaction still has mildly elevated ALT levels, whereas the other two patients have normal ALT levels. We also noted that on the 5th week there was a transient elevation of serum ALT levels in two patients. No adverse effects or rejection episodes were noted. In conclusion, lamivudine is a beneficial and well-tolerated therapy in OLT patients with recurrent HBV infection. We are studying the effect of lamivudine in other patients and for a longer period of time.

Liver biopsy in liver transplantation: no additional risk of infections in patients with choledochojejunostomy

BACKGROUND/AIMS

This study aimed to determine whether there is an increased infectious risk following liver biopsy in liver transplant patients with choledochojejunostomy.

METHODS

We evaluated the incidence of liver-biopsy-related sepsis in a consecutive series of 27 patients who underwent choledochojejunostomy, either during the transplant procedure (17 patients) or later following biliary complications (10 patients). We evaluated another 138 patients as a control group who had orthotopic liver transplantation during the same period and underwent duct-to-duct anastomosis. All liver biopsies had routine, prior ultrasound evaluation to detect dilated biliary ducts.

RESULTS

In the 27 patients who underwent choledochojejunostomy, 96 liver biopsies were performed: the sepsis rate was 3.12% per biopsy (n = 96) or 7.4% per patient (n = 27). However, despite a normal ultrasound, subsequent ERCP demonstrated biliary obstruction in one patient. Thus the rate of sepsis was 2.1% per biopsy or 3.7 per patient. In the control group 338 liver biopsies were performed: the sepsis rate was 1.5% per biopsy (n = 338) or 2.9% per patient (n = 138). The difference was not significant. All septic episodes had positive blood cultures for a single enteric microorganism, and all responded to antibiotics

CONCLUSIONS

Our data do not suggest that liver-transplanted patients with choledochojejunostomy are more at risk of sepsis following liver biopsy, providing there is no "occult" biliary obstruction; therefore, they do not require prophylactic antibiotics as has been suggested by other authors.

Monoclonal antibodies against eosinophils in liver allograft rejection

There has been recent interest in eosinophils as a histological diagnostic marker of liver allograft rejection. However, the reliability of counting eosinophils in sections stained with hematoxylin and eosin (H&E) has not been evaluated previously. We quantified eosinophils in 10 day-5 protocol liver biopsy specimens in 10 patients. The control groups were 5 patients with cytomegalovirus infection, 5 patients with obscure liver dysfunction, and 6 patients with HCV infection. Eosinophil count was assessed using H&E and by specific monoclonal antibody staining using (1) an anti-ECP antibody (EG2) and (2) a monoclonal antibody against human eosinophil major basic protein (MBP) (BMK-13). The average percentage of the total inflammatory infiltrate of eosinophils in portal tracts was 9% in the moderate to severe rejection group as compared with 0.25% in the mild rejection group (P < .001) and 0% in the control group (P < .001). The eosinophil count decreased markedly after successful treatment of rejection. The H&E staining correlated with MBP+ the (BMK-13 immunoreactive) cells but were more numerous with BMK-13. BMK-13 also stained significantly more cells when compared with EG2 (P < .01). This difference may be because EG2 staining only activated eosinophils, whereas BMK-13 is a pan-eosinophilic maker, regardless of activation. This study confirms that eosinophils are a specific feature of acute cellular rejection and are an aid to its diagnosis. BMK-13 is a useful pan-eosinophilic marker that is more efficient in obtaining eosinophil count when compared with H&E.

Morphometric image analysis and eosinophil counts in human liver allografts

Histology of liver allografts is the gold standard for diagnosis of acute cellular rejection. However, scoring the severity of rejection and distinguishing it from other infiltrations is not easy. Only one group has evaluated biopsies morphometrically and also suggested that eosinophils are a specific diagnostic feature. We quantitated eosinophil count in 92 biopsies in a group of 25 patients and, in another group of 30 patients, used morphometric image analysis to measure the cross-sectional area and cell density in each portal tract in day 5 protocol liver biopsies. Rejection was diagnosed by pathological evaluation confirmed with clinical and biochemical graft dysfunction graded histologically into mild or moderate-to-severe. The control groups were five patients with no rejection, nine patients with CMV infection, and eight biopsies in eight patients for whom the cause of the liver dysfunction was obscure. The cross-sectional area, the inflammatory cell count of each portal tract and the mean portal tract inflammatory cell density (cells/mm2) increased with the severity of rejection. In each case the regression coefficient was statistically significant. Correlating the mean of the total inflammatory cell count with the mean of the portal inflammatory cell density (cell/mm2) gave far better separation of the mild rejection and moderate-to-severe rejection groups. Eosinophils were specific for the presence of acute cellular rejection and increased with the severity of rejection. They were absent in the no rejection group, in the CMV group and in those with obscure liver dysfunction. The eosinophil count fell markedly following treatment of rejection.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous haemoperitoneum caused by ruptured varices in a patient with non-cirrhotic portal hypertension

OBJECTIVE

To report the case of a patient with a spontaneous, massive and fatal intraperitoneal haemorrhage from porto-systemic collaterals, caused by portal hypertension. We also review the cases of 18 cirrhotic patients with spontaneous bleeding of intraperitoneal varices and no previous abdominal surgery reported in the literature.

PATIENT

A 21-year-old man with nodular regenerative hyperplasia, who had not undergone any previous surgery and who had large oesophageal varices diagnosed 3 years previously.

CONCLUSION

To our knowledge, this is the first case of spontaneous intra-abdominal bleeding from collateral vessels in a non-cirrhotic patient.

Autoimmune cholangiopathy: part of the spectrum of autoimmune chronic active hepatitis

We describe four patients with features overlapping those of primary biliary cirrhosis and autoimmune chronic active hepatitis. Three were female and one was male; only one was symptomatic. Serum biochemical study showed increases in alkaline phosphatase and alpha-glutamyltranspeptidase levels. Markers of hepatitis B and C viruses were absent. In all four patients, serum mitochondrial antibodies could not be detected on immunofluorescence study and serum M2 antibodies were absent. All four patients had high titers of serum antinuclear antibody of diffuse type. Serum actin antibodies were detected in all four patients. Liver biopsy specimens showed histological features of primary biliary cirrhosis, with marked cellular infiltration of the portal areas and bile duct damage. Intralobular inflammation and piecemeal necrosis were mild. Three patients were treated with prednisolone and showed rapid clinical and biochemical remission. Serial liver biopsy specimens showed reduced inflammation, but bile duct lesions persisted. These patients probably form a subgroup of autoimmune chronic active type 1 with predominant bile duct damage. The subgroup might be termed autoimmune cholangiopathy.