Liver transplantation for viral hepatitis-associated cirrhosis

Role of lamivudine in the posttransplant prophylaxis of chronic hepatitis B virus and hepatitis delta virus coinfection

BACKGROUND

Posttransplant combined lamivudine (LAM) and immunoglobulin (HBIg) prophylaxis is the gold standard in the case of single hepatitis B virus (HBV), but is still not recommended in the case of patients coinfected with hepatitis delta virus (HDV).

METHODS

We compared two consecutive groups of chronic HDV carriers who survived >6 months after liver transplantation of the risk of recurrence, survival and HBIg requirements: 21 received passive prophylaxis (HBIg group) and 25 were treated with combined prophylaxis (LAM+HBIg group). The immunoprophylaxis schedule was the same in both groups: intramuscular HBIg targeted to maintain anti-HBs levels of >500 IU/L during the first 6 posttransplant months and >200 IU/L thereafter.

RESULTS

The mean length of follow-up in the two groups was significantly different (133 vs. 40 months; P<0.001). None of the patients in either group developed recurrent hepatitis, and the 3-year actuarial survival rate was 100% in both groups. During the first 6 months, HBIg requirement was 38% lower in the LAM+HBIg group although similar anti-HBs target levels were maintained, leading to significantly lower costs (5,000 Euros in the first year and 500 Euros in the second).

CONCLUSIONS

This is the first study of large and homogeneous cohort of long-term HDV coinfected liver transplant survivors showing the absence of HBV recurrence under combined prophylaxis. Although retrospective, our results suggest that combined anti-HBV prophylaxis should also be preferred to single immunoprophylaxis in patients with HDV coinfection because it allows significant cost savings in the first two posttransplant years.

No hepatitis recurrence using combination prophylaxis in HBV-positive liver transplant recipients with YMDD mutants

Recurrence of hepatitis B impairs the outcome of liver transplantation (OLT). In serum hepatitis B virus (HBV)-DNA-positive recipients, prophylaxis using lamivudine and immunoglobulins (HBIg) reduces the risk of recurrence, but it is undefined whether this regimen also protects candidates with YMDD mutants. Seventeen OLT viraemic candidates received pre-emptive lamivudine followed by post-OLT prophylaxis with lamivudine and HBIg. Both sera and liver biopsies were prospectively collected and high-sensitive polymerase chain reaction (PCR) assay was applied for HBV-DNA detection. Finally, the presence of YMDD mutants was explored in all PCR-positive samples. All patients remained hepatitis B recurrence-free after a mean follow up of 32 months. By PCR, serum HBV-DNA was detectable in 64.3% of cases at OLT-baseline, in 64.7% under combined prophylaxis and in 58.8% in patients (70.5% of the total) with a minimum follow up of 24 months. At OLT-baseline, YMDD mutants were found in 44.4% of patients. After OLT, mutants were present in 50% of patients but only in 16.6% of cases in the long period. Although 41% of the native livers and 42.8% of the analysed grafts harboured HBV-DNA, YMDD mutants were detected in 57% of the native positive livers. YMDD mutants were largely detected both at OLT-baseline and post-OLT, but their presence decreased over time. Regardless of the presence of YMDD mutants, no hepatitis B recurrence was observed in our OLT recipients using pre-emptive lamivudine followed by continuous prophylaxis with lamivudine and HBIg.

Liver transplantation

The growing disparity between available organs for liver transplantation and the number of waiting recipients has prompted significant debate over organ allocation and distribution. In light of this debate, recipient selection and prediction of factors relating to outcome have become increasingly important. Current immunosuppressive regimens provide excellent short-and long-term survival for patients and grafts. Increasingly, efforts are being made to decrease or withdraw immunosuppression late after transplantation to minimize long-term side effects. Viral disease, particularly cytomegalovirus infection, results in significant morbidity and mortality in patients. However, strategies for targeting high-risk patients with prophylactic antiviral therapy have been successful in reducing the incidence of cytomegalovirus disease. Recurrent viral hepatitis following liver transplantation may limit long-term graft success. Lamivudine appears to limit recurrent infection with hepatitis B virus in a significant number of patients who develop this condition following liver transplantation and may represent a cost savings over hepatitis B immunoglobulin. Although the overall survival of patients with chronic hepatitis C virus infection after orthotopic liver transplantation is excellent, significant morbidity and mortality occur in the subset of patients with severe recurrent disease. Interferon may delay the onset of disease in patients infected with hepatitis C virus following orthotopic liver transplantation, and investigation continues into antiviral therapy in this group of patients.