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Arora A, Anand AC, Kumar A, Singh SP, Aggarwal R, Dhiman RK, Aggarwal S, Alam S, Bhaumik P, Dixit VK, Goel A, Goswami B, Kumar A, Kumar M, Madan K, Murugan N, Nagral A, Puri AS, Rao PN, Saraf N, Saraswat VA, Sehgal S, Sharma P, Shenoy KT, Wadhawan M. INASL Guidelines on Management of Hepatitis B Virus Infection in Patients receiving Chemotherapy, Biologicals, Immunosupressants, or Corticosteroids. J Clin Exp Hepatol 2018; 8:403-431. [PMID: 30568345 PMCID: PMC6286881 DOI: 10.1016/j.jceh.2018.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 06/10/2018] [Indexed: 02/09/2023] Open
Abstract
Hepatitis B Virus (HBV) reactivation in patients receiving chemotherapy, biologicals, immunosupressants, or corticosteroids is emerging to be an important cause of morbidity and mortality in patients with current or prior exposure to HBV infection. These patients suffer a dual onslaught of illness: one from the primary disease for which they are receiving the culprit drug that led to HBV reactivation, and the other from HBV reactivation itself. The HBV reactivation not only leads to a compromised liver function, which may culminate into hepatic failure; it also adversely impacts the treatment outcome of the primary illness. Hence, identification of patients at risk of reactivation before starting these drugs, and starting treatment aimed at prevention of HBV reactivation is the best strategy of managing these patients. There are no Indian guidelines on management of HBV infection in patients receiving chemotherapy, biologicals, immunosupressants, or corticosteroids for the treatment of rheumatologic conditions, malignancies, inflammatory bowel disease, dermatologic conditions, or solid-organ or bone marrow transplantation. The Indian National Association for Study of the Liver (INASL) had set up a taskforce on HBV in 2016, with a mandate to develop consensus guidelines for management of various aspects of HBV infection, relevant to India. In 2017 the taskforce had published the first INASL guidelines on management of HBV infection in India. In the present guidelines, which are in continuation with the previous guidelines, the issues on management of HBV infection in patients receiving chemotherapy, biologicals, immunosupressants, or corticosteroids are addressed.
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Key Words
- ACLF, Acute-on-Chronic Liver Failure
- AFP, Alphafetoprotein
- ALT, Alanine Aminotransferase
- Anti-HBc, Antibodies to Hepatitis B Core Antigen
- Anti-HBs, Antibodies to Hepatitis B Surface Antigen
- CHB, Chronic Hepatitis B
- CHOP, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone
- CKD, Chronic Kidney Disease
- DILI, Drug-Induced Liver Injury
- DNA, Deoxyribonucleic Acid
- ETV, Entecavir
- GRADE, Grading of Recommendations, Assessment, Development and Evaluation
- HAV, Hepatitis A Virus
- HBIG, Hepatitis B Immune Globulin
- HBV DNA, Hepatitis B Virus Deoxyribonucleic Acid
- HBV, Hepatitis B Virus
- HBcAg, Hepatitis B Core Antigen
- HBeAg, Hepatitis B Envelope Antigen
- HBsAg, Hepatitis B Surface Antigen
- HDV, Hepatitis D Virus
- HEV, Hepatitis E Virus
- HLA, Human Leukocyte Antigen Class I
- INASL, Indian National Association for Study of the Liver
- LAM, Lamivudine
- NAs, Nucleos(t)ide Analogs
- NHL, Non-Hodgkin’s Lymphoma
- NK, Natural Killer
- PegIFN-α, Pegylated Interferon Alpha
- RA, Rheumatoid Arthritis
- SLE, Systemic Lupus Erythematosus
- TAF, Tenofovir Alafenamide
- TDF, Tenofovir Disoproxil Fumarate
- TLC, Total Leucocyte Count
- ULN, Upper Limit of Normal
- cancer
- cccDNA, Covalently Closed Circular Deoxyribonucleic Acid
- chemotherapy
- hepatitis B
- immunosupressants
- liver failure
- rcDNA, Relaxed-Circular Deoxyribonucleic Acid
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Affiliation(s)
- Anil Arora
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Ashish Kumar
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Shivaram P. Singh
- Department of Gastroenterology, S.C.B. Medical College, Cuttack, India
| | - Rakesh Aggarwal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shyam Aggarwal
- Department of Medical Oncology, Sir Ganga Ram Hospital, New Delhi, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Pradeep Bhaumik
- Department of Medicine, Agartala Govt. Medical College (AGMC), Agartala, India
| | - Vinod K. Dixit
- Department of Gastroenterology, Institute of Medical Sciences Banaras Hindu University, Varanasi, India
| | - Ashish Goel
- Department of Hepatology, Christian Medical College, Vellore, India
| | - Bhabadev Goswami
- Department of Gastoenterology, Gauhati Medical College, Guwahati, India
| | - Ashok Kumar
- Department of Rheumatology, Fortis Flt Lt Rajan Dhall Hospital, New Delhi, India
| | - Manoj Kumar
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kaushal Madan
- Gastroenterology & Hepatology, Max Smart Super Speciality Hospital, New Delhi, India
| | | | - Aabha Nagral
- Department of Gastroenterology, Jaslok and Apollo Hospitals, Mumbai, India
| | - Amarender S. Puri
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
| | - Padaki N. Rao
- Hepatology, Asian Institute Of Gastroenterology, Hyderabad, India
| | - Neeraj Saraf
- Hepatology, Medanta - The Medicity, Gurugram, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sanjeev Sehgal
- Institute of Liver Transplantation and Regenerative Medicine, Medanta - The Medicity, Gurugram, India
| | - Praveen Sharma
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Manav Wadhawan
- Hepatology & Liver Transplant (Medicine), Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Hospital, Delhi, India
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Shouval D. Expanding the donor pool for liver transplant recipients using HBsAg positive grafts. J Hepatol 2014; 61:717-9. [PMID: 25038488 DOI: 10.1016/j.jhep.2014.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 07/10/2014] [Indexed: 12/26/2022]
Affiliation(s)
- Daniel Shouval
- Liver Unit, Institute for Gastroenterology and Hepatology, Hadassah-Hebrew University Hospital, Jerusalem, Israel.
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Chotiyaputta W, Pelletier SJ, Fontana RJ, Lok ASF. Long-term efficacy of nucleoside monotherapy in preventing HBV infection in HBsAg-negative recipients of anti-HBc-positive donor livers. Hepatol Int 2010; 4:707-15. [PMID: 21286341 DOI: 10.1007/s12072-010-9188-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Accepted: 07/09/2010] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIM Transmission of hepatitis B virus (HBV) infection occurs in up to 87.5% of HBsAg-negative recipients of anti-HBc-positive donor livers in the absence of HBV prophylaxis. There is no standardized prophylactic regimen to prevent HBV infection in this setting. The aim of this study was to determine the long-term efficacy of nucleoside analogue to prevent HBV infection in this setting. METHODS A retrospective study of HBsAg-negative patients receiving liver transplantation (LT) from anti-HBc-positive donors during a 10-year period. RESULTS Twenty patients were studied, mean age was 50.2 ± 8.3 years, 40% were men, and 90% were Caucasian. The median MELD score at the time of LT was 18 (12-40). None of the patients received hepatitis B immune globulin. Eighteen patients received nucleoside analogue monotherapy: 10 received lamivudine and 8 received entecavir. None of these 18 patients developed HBV infection after a median follow up of 32 (1-75) months. One patient received a second course of hepatitis B vaccine 50 months after LT with anti-HBs titer above 1,000 mIU/mL. Lamivudine was discontinued and the patient remained HBsAg negative 18 months after withdrawal of lamivudine. Two patients who were anti-HBs positive before LT were not started on HBV prophylaxis after LT; both developed HBV infection after LT. CONCLUSIONS Nucleoside monotherapy is sufficient in preventing HBV infection in HBsAg-negative recipients of anti-HBc-positive donor livers. HBV prophylaxis is necessary in anti-HBs-positive recipients of anti-HBc-positive donor livers.
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Abstract
BACKGROUND & AIMS Although hepatitis B virus (HBV) transmission after liver transplantation of grafts from HBsAg-negative, anti-HBc positive donors is well established, the growing organ shortage favours the use of such marginal grafts. We systematically evaluated the risk of HBV infection after liver transplantation with such grafts and the effect of anti-HBV prophylaxis. METHODS We performed a literature review over the last 15 years identifying 39 studies including 903 recipients of anti-HBc positive liver grafts. RESULTS Recurrent HBV infection developed in 11% of HBsAg-positive liver transplant recipients of anti-HBc positive grafts, while survival was similar (67-100%) to HBsAg-positive recipients of anti-HBc negative grafts. De novo HBV infection developed in 19% of HBsAg-negative recipients being less frequent in anti-HBc/anti-HBs positive than HBV naive cases without prophylaxis (15% vs 48%, p<0.001). Anti-HBV prophylaxis reduced de novo infection rates in both anti-HBc/anti-HBs positive (3%) and HBV naive recipients (12%). De novo infection rates were 19%, 2.6% and 2.8% in HBsAg-negative recipients under hepatitis B immunoglobulin, lamivudine and their combination, respectively. CONCLUSIONS Liver grafts from anti-HBc positive donors can be safely used, preferentially in HBsAg-positive or anti-HBc/anti-HBs positive recipients. HBsAg-negative recipients should receive prophylaxis with lamivudine, while both anti-HBc and anti-HBs positive recipients may need no prophylaxis at all.
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Verna EC, Brown RS. Hepatitis C and liver transplantation: enhancing outcomes and should patients be retransplanted. Clin Liver Dis 2008; 12:637-59, ix-x. [PMID: 18625432 DOI: 10.1016/j.cld.2008.03.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hepatitis C (HCV)-related end-stage liver disease is the most common indication for liver transplantation. Safe expansion of the donor pool with improved rates of deceased donation and more widespread use of living and extended criteria donation are likely to decrease wait list mortality. In addition, improved antiviral treatments and a better understanding of the delicate balance between under- and over-immunosuppression in this population are needed. Finally, when recurrent advanced fibrosis occurs, the criteria for patient selection for retransplantation remain widely debated. This article reviews the literature on these topics and the work being done in each area to maximize outcomes in patients receiving transplants for HCV-related cirrhosis.
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Affiliation(s)
- Elizabeth C Verna
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA
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Takemura N, Sugawara Y, Tamura S, Makuuchi M. Liver transplantation using hepatitis B core antibody-positive grafts: review and university of Tokyo experience. Dig Dis Sci 2007; 52:2472-7. [PMID: 17805972 DOI: 10.1007/s10620-006-9656-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2006] [Accepted: 10/15/2006] [Indexed: 01/10/2023]
Abstract
Hepatitis B surface antigen-negative and hepatitis B core antibody-positive grafts were considered unsuitable for transplantation. The number of potential recipients for liver transplantation now exceeds that of potential donor organs, which has led us to reevaluate the feasibility of these grafts. Several strategies involving prophylactic administration of hepatitis B immunoglobulin and/or lamivudine to transplant recipients have been proposed. At the University of Tokyo, we have continued to use hepatitis B immunoglobulin monoprophylaxis with zero recurrence. In this article we report our experience with the use of hepatitis B surface antigen-negative/hepatitis B core antibody-positive grafts with hepatitis B immunoglobulin monotherapy. We conducted a review of the literature regarding the feasibility of these grafts to reconfirm optimal prophylactic strategies for preventing de novo hepatitis B virus infection in transplant recipients.
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Affiliation(s)
- Nobuyuki Takemura
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Jankowska I, Pawłowska J, Teisseyre M, Kaliciński P, Kamiński A, Czubkowski P, Cielecka-Kuszyk J, Kluge P, Pronicki M, Socha J. Prevention of de Novo Hepatitis B Virus Infection by Vaccination and High Hepatitis B Surface Antibodies Level in Children Receiving Hepatitis B Virus Core Antibody-Positive Living Related Donor Liver: Case Reports. Transplant Proc 2007; 39:1511-2. [PMID: 17580175 DOI: 10.1016/j.transproceed.2006.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2006] [Accepted: 11/02/2006] [Indexed: 11/15/2022]
Abstract
Transmission of hepatitis B virus (HBV) infection from donors negative for hepatitis B surface antigen (HBsAg) but positive for antibody to hepatitis B core antigen (anti-HBc) have been reported. The aim of our study was to evaluate the outcomes of recipients who received liver grafts from living related donors with serological evidence of previous exposure to hepatitis B virus (HBsAg-negative/anti-HBc-positive) after recipient vaccination against HBV before and after liver transplantation.
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Affiliation(s)
- I Jankowska
- Departments of Gastroenterology, Hepatology, and Immunology, Children's Memorial Health Institute, Al. Dzieci Polskich 20, Warsaw, Poland
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Gallegos-Orozco JF, Vargas HE. Should antihepatitis B virus core positive or antihepatitis C virus core positive subjects be accepted as organ donors for liver transplantation? J Clin Gastroenterol 2007; 41:66-74. [PMID: 17198068 DOI: 10.1097/01.mcg.0000225636.60404.bf] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Since the introduction of liver transplantation as a routine surgical procedure for the treatment of end-stage liver disease, there has been an increasing gap between the number of available grafts and the number of patients on the waiting list. This has led transplant centers to expand the donor pool by different means. One of them has been the introduction of living donor liver transplantation. Other strategies include using less than optimal allografts from deceased donors, the so-called marginal donors, which include the use of grafts from older subjects, livers with moderate amounts of steatosis, or from donors with markers of past or current infection with hepatitis viruses who have absent or minimal liver biochemical or histologic injury. In this review, we will focus on the current use of allografts from donors with antihepatitis B core antibody and/or antibodies against hepatitis C virus in cadaveric and living donor liver transplantation.
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Affiliation(s)
- Juan F Gallegos-Orozco
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Saab S, Chang AJ, Comulada S, Geevarghese SK, Anselmo RDM, Durazo F, Han S, Farmer DG, Yersiz H, Goldstein LI, Ghobrial RM, Busuttil RW. Outcomes of hepatitis C- and hepatitis B core antibody-positive grafts in orthotopic liver transplantation. Liver Transpl 2003; 9:1053-61. [PMID: 14526400 DOI: 10.1053/jlts.2003.50208] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The use of hepatitis B core antibody (HBcAb)- and hepatitis C virus antibody (HCV+) liver grafts for transplantation in selected populations has not affected patient and graft survival. We reexamined the clinical outcomes of using these HBcAb+ and HCV+ grafts at our institution, in addition to studying recipients of combined HBcAb+/HCV+ grafts. We identified 377 patients who underwent transplantation for either hepatitis B and/or hepatitis C, or received both HBcAb+ and HCV+ grafts. Patient and graft survival at 5 years posttransplantation was 73% and 71%, respectively, in the HBcAb+ grafts compared with 81% and 75% in the HBcAb- grafts (P =.65; P =.94). For HCV+ grafts, patient and graft survival at 5 years posttransplantation was 89% and 73%, respectively, compared with 69% and 59% in the HCV- grafts; (P =.22; P =.77). The 5-year patient and graft survival rate in those who received combined HBcAb+/HCV+ grafts was 74% and 69%, respectively, and there was no statistical difference compared with the HBcAb+ and HCV+ grafts (P =.76; P =.90). The 5-year patient and graft survival rate in patients who received dual HBV prophylaxis with hepatitis B immunoglobulin (HBIg) and lamivudine was 88% and 84%, respectively, which was significantly higher than for patients who received single prophylaxis or no prophylaxis (P <.01; P =.02). Our study supports previous observations that patient and graft survival is not affected with the use of HBcAb+ and HCV+ grafts, and that dual prophylaxis with HBIg and lamivudine offers substantial survival benefits. Furthermore, the use of combined HBcAb+/HCV+ grafts did not impact patient or graft survival. This provides a potential new pool of donor livers that can be used for transplantation in select patients.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, Division of Digestive Diseases, Dumont-UCLA Liver Transplant Center, University of California Los Angeles, 90095, USA.
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Komokata T, Nishida S, Ganz S, Suzuki T, Olson L, Tzakis AG. The impact of donor chemical overdose on the outcome of liver transplantation. Transplantation 2003; 76:705-8. [PMID: 12973114 DOI: 10.1097/01.tp.0000079916.07254.3d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND To overcome the critical shortage of liver grafts, many centers have been widening the acceptance criteria for liver donation. Use of liver grafts from victims who have suffered chemical overdose (COD) may be one option that could help to expand the donor pool. However, this practice has been poorly documented. METHODS Of 1,195 orthotopic liver transplantations performed at our institution between June 1994 and March 2001, 22 involved livers (1.8%) were retrieved from COD donors. Donor and recipient characteristics and posttransplantation outcomes were analyzed retrospectively. RESULTS The main chemicals causing brain death of the donor were carbon monoxide (n=4), cocaine (n=4), tricyclic antidepressants (n=3), 3,4-methylenedioxy- methamphetamine (n=2), opiates (n=2), aspirin (n=1), gamma hydroxybutyrate (n=1), heroin (n=1), insulin (n=1), verapamil (n=1), barbiturate (n=1), and brompheniramine/phenylpropanolamine (n=1). Primary nonfunction developed in one patient who had received a liver from an 3,4-methylenedioxymethamphetamine-intoxicated donor. Another patient died of fungal meningitis 10 days after transplantation with a functioning graft. The remaining 20 patients experienced acceptable early graft function, as demonstrated by initial mean peak values of bilirubin (4.8 mg/dL), aspartate aminotransferase (624 U/L), and alanine aminotransferase (730 U/L). One-year graft survival rate estimated by the Kaplan-Meier method was 86%. CONCLUSIONS Satisfactory outcomes of graft function were achieved in orthotopic liver transplantations from COD donors. The cautious use of liver grafts from selected COD donors may be a worthwhile method of increasing the availability of scarce donor organs.
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Affiliation(s)
- Teruo Komokata
- Second Department of Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
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López-Navidad A, Caballero F. Extended criteria for organ acceptance. Strategies for achieving organ safety and for increasing organ pool. Clin Transplant 2003; 17:308-24. [PMID: 12868987 DOI: 10.1034/j.1399-0012.2003.00119.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The terms extended donor or expanded donor mean changes in donor acceptability criteria. In almost all cases, the negative connotations of these terms cannot be justified. Factors considered to affect donor or organ acceptability have changed with time, after showing that they did not negatively affect graft or patient survival per se or when the adequate measures had been adopted. There is no age limit to be an organ donor. Kidney and liver transplantation from donors older than 65 years can have excellent graft and patient actuarial survival and graft function. Using these donors can be from an epidemiological point of view the most important factor to esablish the final number of cadaveric liver and kidney transplantations. Organs with broad structural parenchyma lesion with preserved functional reserve and organs with reversible functional impairment can be safely transplanted. Bacterial and fungal donor infection with the adequate antibiotic treatment of donor and/or recipient prevents infection in the latter. The organs, including the liver, from donors with infection by the hepatitis B and C viruses can be safely transplanted to recipients with infection by the same viruses, respectively. Poisoned donors and non-heart-beating donors, grafts from transplant recipients, reuse of grafts, domino transplant and splitting of one liver for two recipients can be an important and safe source of organs for transplantation.
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Affiliation(s)
- Antonio López-Navidad
- Department of Organ & Tissue Procurement for Transplantation, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Nery JR, Nery-Avila C, Reddy KR, Cirocco R, Weppler D, Levi DM, Nishida S, Madariaga J, Kato T, Ruiz P, Schiff E, Tzakis AG. Use of liver grafts from donors positive for antihepatitis B-core antibody (anti-HBc) in the era of prophylaxis with hepatitis-B immunoglobulin and lamivudine. Transplantation 2003; 75:1179-86. [PMID: 12717200 DOI: 10.1097/01.tp.0000065283.98275.fe] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The increasing demand for transplantation has resulted in a trend toward using virologically compromised donors. We reviewed our experience with liver grafts from hepatitis-B surface antigen (HBsAg)(-), antibody to core antigen (anti-HBc)(+) donors. METHODS Sixty-two liver transplants using HBsAg(-), anti-HBc(+) donors were studied. The decision to use prophylaxis was based on the presence or absence of donor and recipient risk factors for posttransplant hepatitis-B virus (HBV) transmission or reinfection. If the donor or recipient showed positive HBVDNA, hepatitis-B immunoglobulin (HBIg) and lamivudine were used. If both donor and recipient HBVDNA were negative, a choice between lamivudine and no prophylaxis was made on the basis of presence or absence of HBsAg and antibody to the surface antigen (anti-HBs) in the recipient. RESULTS No death or graft loss could be ascribed to HBV. Mild HBV infection occurred in two patients who were not taking the recommended prophylaxis. Among the other 60 patients, 1 showed positive e antigen (HBeAg) early after transplantation, and 2 (1 with recurrent cancer, 1 with HIV infection) showed HBsAg(+). None of the three patients had any other evidence of HBV infection. Forty-seven patients underwent liver biopsies. Changes consistent with hepatitis were observed in 26, and 24 had HCV infection; immunostains for HBV antigens were negative in all cases, and 7 showed positive HBVDNA. CONCLUSIONS A selective protocol based on donor and recipient risk factors for post-liver transplant HBV infection can prevent hepatitis-B infection and avoid unnecessary administration of antiviral prophylaxis in recipients of HBsAg(-), anti-HBc(+) liver allografts.
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Affiliation(s)
- Jose R Nery
- University of Miami School of Medicine, Department of Surgery, Division of Liver/GI Transplantation, Miami, FL, USA.
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