Lamivudine without HBIg for prevention of graft reinfection by hepatitis B: long-term follow-up

Immunisations in solid-organ transplant recipients

Solid-organ transplant recipients are at increased risk of various infectious diseases, some of which are vaccine preventable mmunisations are among the most efficient interventions available. Solid-organ tranplant recipients would greatly benefit from effective immunisations, provided the recommendations are based on a careful risk-benefit analysis in which the effectiveness of the vaccine is weighed against possible adverse reactions, including graft rejection. In this review, we summarise the data from studies on relevant immunisations in solid-organ transplant recipients. The major issues are the immunogenicity and safety of immunisations, the factors associated with poor immune response, and recommendations for immunisation schemes.

A concise update on the status of liver transplantation for hepatitis B virus: the challenges in 2002

Significant improvements in both patient and graft survival after orthotopic liver transplantation (OLT) for hepatitis B virus (HBV)-related liver failure have been made during the last decade. Recurrence of HBV infection has decreased, even in high-risk patients. Despite ongoing progress, challenges remain for the next millennium, including the determination of cost-effective dosing strategies, treatment of HBV infection in liver transplant recipients, and ramifications of the use of new antiviral agents, specifically, the appearance of resistant strains. This review summarizes the relevant history of OLT for chronic viral hepatitis B, details accepted preventive and therapeutic treatments, and discusses ongoing experimental trials. Emphasis also is placed on new approaches in transplantation as they impact on the care of HBV-infected patients.

Favorable outcome of orthotopic liver transplantation in a patient with subacute liver failure due to the emergence of a hepatitis B YMDD escape mutant virus

BACKGROUND/AIMS

Patients with end-stage liver disease due to chronic hepatitis B infection in whom a YMDD escape hepatitis B virus (HBV) mutant has emerged under lamivudine treatment are generally denied liver transplantation (OLT).

METHODS

We report the case of a male patient who was started on prophylactic treatment with lamivudine in the context of recurrent episodes of HBV reactivation during high dose immunosuppressive therapy for relapsing severe pulmonary sarcoidosis.

RESULTS

Following the emergence of a YMDD escape mutant virus under lamivudine treatment, he developed subacute liver failure requiring liver transplantation. The patient was treated with a combination of intravenous hepatitis B immune globulin (HBIG) which was started perioperatively and also continued lamivudine after OLT. Twelve months after OLT, there was no evidence of HBV reinfection of the liver graft with the use of HBIG and lamivudine.

CONCLUSIONS

This observation suggests that emergence of the YMDD mutation is not a contra-indication to OLT, providing adequate immunoprophylaxis using HBIG and lamivudine combination therapy.

Hepatitis B and C in the liver transplant recipient: current understanding and treatment

1. Liver disease related to chronic viral hepatitis is the leading indication for orthotopic liver transplantation (OLT) worldwide. 2. The natural history of hepatitis B virus infection has been dramatically modified, and outcome has improved substantially in the last decade with the use of hepatitis B immunoglobulin and lamivudine. 3. Hepatitis C virus (HCV) recurrence, defined by histological injury, is almost universal, and a subset of patients (20% to 30%) develops allograft cirrhosis by the fifth year post-OLT. 4. Unfortunately, antiviral therapy for hepatitis C post-OLT, even when initiated preemptively before the development of histological recurrence in the first few weeks post-OLT, has failed to alter the natural history of HCV disease recurrence. 5. HCV-related allograft cirrhosis is associated with a high rate of decompensation and mortality.

Prevention of fungal and hepatitis virus infections in liver transplantation

Invasive fungal infections, especially those caused by Candida albicans, and recurrence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection after transplantation are common complications in orthotopic liver transplant (OLT) recipients. Candida species account for >50% of all invasive fungal infections, which occur in 10%--15% of OLT recipients. The epidemiology and pathogenesis of invasive fungal infections are unique to each type of organism. Fluconazole is effective and safe in the prevention of Candida infection after OLT. Preventive measures against Aspergillus or Cryptococcus remain ill defined. Both HBV and HCV recur almost universally after OLT in infected individuals. The natural course of HBV and HCV, leading to end-stage liver damage, is accelerated. In OLT patients, administration of immunoglobulin with high titers against HBV, alone and/or in combination with lamivudine, immediately after transplantation reduces the recurrence of HBV. The combination of interferon and ribavirin is mildly effective in OLT patients who have evidence of recurrent hepatitis, and additional alternatives are being evaluated.

Liver transplantation

Continued discussion over organ allocation and distribution remained a focal point in the field of liver transplantation in the year 2000. Despite the ongoing debate, no significant changes were implemented in the current allocation system. By far, the most widely discussed topic in liver transplantation this year was live donor adult-to-adult liver transplantation. Several authors reported on their initial experience, with both recipient and donor outcomes appearing excellent. As the number of transplant centers performing this procedure increases we look forward to further studies regarding the safety and long-term outcome of this innovative procedure. Studies on viral hepatitis after liver transplantation again focused on the problem of recurrent hepatitis B and hepatitis C. Several small studies found benefit in patients with hepatitis B treated with intramuscular hepatitis B immunoglobulin and lamivudine after transplantation. Although breakthrough replication remains a problem in some patients, these studies offer hope that combination therapy for hepatitis B may provide improved long-term graft survival in these patients. In patients with hepatitis C, several studies focused on identifying risk factors to predict graft recurrence of the virus after liver transplantation. Both cellular rejection and level of viral replication may be important predictors of recurrent hepatitis C virus in the graft. Early treatment reports using interferon and ribavirin suggest that some patients may have a viral response during therapy; however, it is short lived, and tolerance of medication is difficult. Certainly, we look forward to further studies looking at means of prevention and treatment of viral hepatitis in patients undergoing liver transplantation.

Liver transplantation for hepatocellular carcinoma

OBJECTIVE

To analyze patient and tumor characteristics that influence patient survival to select patients who would most benefit from liver transplantation.

SUMMARY BACKGROUND DATA

The selection of patients with hepatocellular carcinoma (HCC) for liver transplantation remains controversial.

METHODS

One hundred twelve patients with nonfibrolamellar HCC who underwent a liver transplant from 1985 to 2000 were reviewed. Survival was calculated using the Kaplan-Meier method, with differences in outcome assessed using the log-rank procedure. Multivariate analysis was then performed using a Cox regression model.

RESULTS

Overall patient survival rates were 78%, 63%, and 57% at 1, 3, and 5 years, respectively. Patients infected with the hepatitis B virus had a worse 5-year survival than those who were not (43% vs. 64%), with most deaths being attributed to recurrent hepatitis B. However, patients with hepatitis B virus who underwent more recent transplants using antiviral therapy fared as well as those who were negative for the virus, showing a 5-year survival rate of 77%. Patients with vascular invasion by tumor had a worse 5-year survival than patients without vascular invasion (33% vs. 68%). Vascular invasion, tumor size greater than 5 cm, and poorly differentiated tumor grade were predictors of tumor recurrence by univariate analysis; however, only vascular invasion remained significant on multivariate analysis: the rate of tumor recurrence at 5 years was 65% in patients with vascular invasion and only 4% for patients without vascular invasion.

CONCLUSIONS

For well-selected patients with HCC, liver transplantation in the current era can achieve equivalent results to transplantation for nonmalignant indications. Vascular invasion is an indicator of high risk of tumor recurrence but is difficult to detect before transplantation.