Hépatite chronique B : situations rares : dialyse, transplantation rénale et traitements pré-emptifs en situation d’immunosuppression

Comparison of clinical outcomes in hepatitis B virus-positive kidney transplant recipients with or without pretransplantation antiviral therapy

BACKGROUND

Antiviral agents have improved the outcomes of hepatitis B virus (HBV)-positive kidney transplant recipients (KTRs). Preemptive therapy has been the main approach to forestall HBV reactivation. We sought to compare prophylactic and preemptive approaches.

METHODS

We divided the 69 HBV-positive KTRs into treatment and historical control groups, according to the time of starting pretransplantation antiviral therapy. The treatment group was further divided into prophylactic and preemptive therapy groups.

RESULTS

The treatment group showed a significant improvement in 10-year graft (82% vs 34%) and patient (91% vs 57%) survivals. Among the historical control group, the main causes of graft failure were patient deaths (68%), which were mostly caused by liver diseases. In contrast, there was no liver-related death in the treatment group. In addition, there was no difference in graft or patient survival between the prophylactic and preemptive groups, but the incidence of HBV reactivation was lower in the prophylactic group. Antiviral therapy was an independent factor for the improved patient survival (P = .005).

CONCLUSIONS

Pretransplantation antiviral therapy is essential to improve clinical outcomes. Prophylactic may be better than preemptive antiviral therapy to decrease HBV reactivation.

[What tests are necessary before registration on the kidney transplant waiting list?]

Before registering a patient on the kidney transplant waiting list, the medical file should be carefully studied looking for factors that may complicate the transplantation. Knowledge of the patient's history and the clinical examination will guide the choice of complementary examinations. The objectives of pretransplantation explorations are : 1) preventing graft rejection ; 2) ensuring that arterial and venous anastomoses are possible ; 3) ensuring that urine can be drained ; 4) preventing post-transplantation infections ; 5) not performing a transplantation on a subject with cancer ; and 6) avoiding any post-transplantation cardiovascular events. The list of the necessary explorations for renal transplantation should be as simple as possible so that registration on the transplant waiting list is not delayed, while being as complete as possible to prevent any complications that may compromise the results. It should be individualized to each patient.