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Current management & future directions in post-liver transplant recurrence of viral hepatitis. JOURNAL OF LIVER TRANSPLANTATION 2021. [DOI: 10.1016/j.liver.2021.100027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Lenci I, Milana M, Grassi G, Manzia TM, Gazia C, Tisone G, Angelico R, Baiocchi L. Hepatitis B virus recurrence after liver transplantation: An old tale or a clear and present danger? World J Gastroenterol 2020; 26:2166-2176. [PMID: 32476783 PMCID: PMC7235198 DOI: 10.3748/wjg.v26.i18.2166] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/12/2020] [Accepted: 04/30/2020] [Indexed: 02/06/2023] Open
Abstract
Hepatitis B virus (HBV) recurrence after liver transplantation (LT) has been described more than 50 years ago. Similarly, to other clinical conditions, in which impairment of host immune defense favors viral replication, early reports described in details recurrence and reactivation of HBV in liver transplant recipients. The evidence of a possible, severe, clinical evolution of HBV reappearance in a significant percentage of these patients, allowed to consider, for some years, HBV positivity a contraindication for LT. Moving from the old to the new millennium this picture has changed dramatically. Several studies contributed to establish efficient prophylactic protocols for HBV recurrence and with the advent of more potent anti-viral drugs an increased control of infection was achieved in transplanted patients as well as in the general immune-competent HBV population. Success obtained in the last decade led some authors to the conclusion that HBV is now to consider just as a “mere nuisance”. However, with regard to HBV and LT, outstanding issues are still on the table: (1) A standard HBV prophylaxis protocol after transplant has not yet been clearly defined; (2) The evidence of HBV resistant strains to the most potent antiviral agents is claiming for a new generation of drugs; and (3) The possibility of prophylaxis withdrawal in some patients has been demonstrated, but reliable methods for their selection are still lacking. The evolution of LT for HBV is examined in detail in this review together with the description of the strategies adopted to prevent HBV recurrence and their pros and cons.
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Affiliation(s)
- Ilaria Lenci
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome 00133, Italy
| | - Martina Milana
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome 00133, Italy
| | - Giuseppe Grassi
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome 00133, Italy
| | - Tommaso M Manzia
- Hepato-Pancreato-Biliary and Transplant, Department of Surgery, University of Rome Tor Vergata, Rome 00133, Italy
| | - Carlo Gazia
- Hepato-Pancreato-Biliary and Transplant, Department of Surgery, University of Rome Tor Vergata, Rome 00133, Italy
| | - Giuseppe Tisone
- Hepato-Pancreato-Biliary and Transplant, Department of Surgery, University of Rome Tor Vergata, Rome 00133, Italy
| | - Roberta Angelico
- Hepato-Pancreato-Biliary and Transplant, Department of Surgery, University of Rome Tor Vergata, Rome 00133, Italy
| | - Leonardo Baiocchi
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome 00133, Italy
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Volpes R, Burra P, Germani G, Manini MA, Caccamo L, Strignano P, Rizza G, Tamè M, Pinna AD, Calise F, Migliaccio C, Carrai P, De Simone P, Valentini MF, Lupo LG, Cordone G, Picciotto FP, Nicolucci A. Switch from intravenous or intramuscular to subcutaneous hepatitis B immunoglobulin: effect on quality of life after liver transplantation. Health Qual Life Outcomes 2020; 18:99. [PMID: 32276633 PMCID: PMC7149917 DOI: 10.1186/s12955-020-01349-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 04/02/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Hepatitis B immunoglobulin (HBIG) therapy is available in intravenous (IV) or intra-muscular (IM) formulations. Recently, a subcutaneous (SC) formulation was introduced. This study evaluated changes in quality of life when liver transplant (LT) recipients were switched from IV or IM HBIG to the SC formulation. METHODS This multicentre, observational study involved adults who had undergone LT at least 1 year prior to study entry. Quality of life was evaluated using the ITaLi-Q questionnaire, assessing the impact of HBIG therapy on daily activities and patient satisfaction, and the SF-36 Health Survey. Patients completed the questionnaires prior to switching from IV or IM HBIG to SC HBIG and 6 months later. RESULTS Eighty-six patients were enrolled; before the switch, 68.6% were receiving IM HBIG and 31.4% IV HBIG. After 6 months, significant improvements in 7 of the 8 ITaLi-Q domains were found, particularly side effects, need for support to adhere to the therapy and satisfaction with the HBIG therapy. Significant improvements in several SF-36 domains were documented, including physical functioning, physical and emotional role limitations, pain, social functioning, physical and mental summary scores. CONCLUSIONS The SC route of administration reduces side effects and their interference with daily life, ameliorates negative feelings, and increases patient autonomy.
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Affiliation(s)
- Riccardo Volpes
- Mediterranean Institute for Transplantation and High Specialization Therapies, Palermo, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit (Gastroenterology), Department of Surgery, Oncology and Gastroenterology,Surgical and Gastroenterological Sciences, Padua University Hospital, Padua, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit (Gastroenterology), Department of Surgery, Oncology and Gastroenterology,Surgical and Gastroenterological Sciences, Padua University Hospital, Padua, Italy
| | - Matteo Angelo Manini
- 1st Division of Gastroenterology and Hepatology, Ca' Granda-Maggiore Polyclinic Hospital, Scientific Institute for Research, Hospitalization, and Health Care, Milan, Italy
| | - Lucio Caccamo
- 1st Division of Gastroenterology and Hepatology, Ca' Granda-Maggiore Polyclinic Hospital, Scientific Institute for Research, Hospitalization, and Health Care, Milan, Italy
| | - Paolo Strignano
- General Surgery and Liver Transplant Center, S. Giovanni Battista Hospital, Turin, Italy
| | - Giorgia Rizza
- General Surgery and Liver Transplant Center, S. Giovanni Battista Hospital, Turin, Italy
| | - Mariarosa Tamè
- Liver and Multiorgan Transplantation, Department of General Surgery, Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Antonio Daniele Pinna
- Liver and Multiorgan Transplantation, Department of General Surgery, Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Fulvio Calise
- Hepatobiliary Surgery and Transplant Unit, Cardarelli Hospital, Naples, Italy
| | - Carla Migliaccio
- Hepatobiliary Surgery and Transplant Unit, Cardarelli Hospital, Naples, Italy
| | - Paola Carrai
- Department of General Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paolo De Simone
- Department of General Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Maria Filippa Valentini
- General Surgery and Liver Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Luigi Giovanni Lupo
- General Surgery and Liver Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | | | | | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Via Tiziano Vecellio, 2, 65124, Pescara, Italy.
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Vatansever S, Farajov R, Yılmaz HC, Zeytunlu M, Kılıç M. The efficiency of low-dose hepatitis B immunoglobulin plus nucleos(t)ide analogs in preventing posttransplant hepatitis B virus recurrence. Turk J Med Sci 2019; 49:1019-1024. [PMID: 31385669 PMCID: PMC7018359 DOI: 10.3906/sag-1808-86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background/aim In this study, the efficiency of using low-dose hepatitis B immunoglobulin (HBIG) plus antiviral treatment according to individual needs has been evaluated in posttransplant hepatitis B virus (HBV) patients. Materials and methods We retrospectively evaluated 179 patients who were admitted between 2009 and 2014. Five thousand IU intravenous HBIG was given in the anhepatic phase, and 400 IU/day intramuscular (IM) HBIG was given in the posttransplant period. After HBsAg seroconversion, 400 IU IM HBIG was continued as prophylaxis every two weeks. Results The average follow-up period was 26 (2–65) months. Seventy patients had hepatocellular carcinoma (HCC). The HBV recurrence was 4.5% in the first year, and 5.8% in the third year. The HBsAg became negative in 11 (2–63) days, and anti-HBs became positive in 9 (1–31) days. HBsAg positivity occurred in 6 patients during the follow-up period. Five of these patients were those who underwent transplantation due to HCC. In 5 of the HCC patients, in whom HBsAg became positive, tumor recurrence was observed after 0.3–9.9 months. HBsAg positivity was more frequently detected in patients with HCC (P = 0.009). Conclusion The HBV recurrence should be evaluated as a predictor of the HCC recurrence in patients who were transplanted due to HCC.
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Affiliation(s)
- Sezgin Vatansever
- Department of Gastroenterology, Atatürk Training and Research Hospital, İzmir Katip Çelebi University, İzmir, Turkey
| | - Rasim Farajov
- Department of Liver Transplantation, Kent Hospital, İzmir, Turkey
| | | | - Murat Zeytunlu
- Department of Liver Transplantation, Kent Hospital, İzmir, Turkey
| | - Murat Kılıç
- Department of Liver Transplantation, Kent Hospital, İzmir, Turkey
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Chauhan R, Lingala S, Gadiparthi C, Lahiri N, Mohanty SR, Wu J, Michalak TI, Satapathy SK. Reactivation of hepatitis B after liver transplantation: Current knowledge, molecular mechanisms and implications in management. World J Hepatol 2018; 10:352-370. [PMID: 29599899 PMCID: PMC5871856 DOI: 10.4254/wjh.v10.i3.352] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/19/2018] [Accepted: 02/09/2018] [Indexed: 02/06/2023] Open
Abstract
Chronic hepatitis B (CHB) is a major global health problem affecting an estimated 350 million people with more than 786000 individuals dying annually due to complications, such as cirrhosis, liver failure and hepatocellular carcinoma (HCC). Liver transplantation (LT) is considered gold standard for treatment of hepatitis B virus (HBV)-related liver failure and HCC. However, post-transplant viral reactivation can be detrimental to allograft function, leading to poor survival. Prophylaxis with high-dose hepatitis B immunoglobulin (HBIG) and anti-viral drugs have achieved remarkable progress in LT by suppressing viral replication and improving long-term survival. The combination of lamivudine (LAM) plus HBIG has been for many years the most widely used. However, life-long HBIG use is both cumbersome and costly, whereas long-term use of LAM results in resistant virus. Recently, in an effort to develop HBIG-free protocols, high potency nucleos(t)ide analogues, such as Entecavir or Tenofovir, have been tried either as monotherapy or in combination with low-dose HBIG with excellent results. Current focus is on novel antiviral targets, especially for covalently closed circular DNA (cccDNA), in an effort to eradicate HBV infection instead of viral suppression. However, there are several other molecular mechanisms through which HBV may reactivate and need equal attention. The purpose of this review is to address post-LT HBV reactivation, its risk factors, underlying molecular mechanisms, and recent advancements and future of anti-viral therapy.
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Affiliation(s)
- Ranjit Chauhan
- Molecular Virology and Hepatology Research Group, Division of BioMedical Sciences, Health Sciences Centre, Memorial University, St. John’s, NL A1B 3V6, Canada
| | - Shilpa Lingala
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, University of Tennessee Health Sciences Center, Memphis, TN 38104, United States
| | - Chiranjeevi Gadiparthi
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, University of Tennessee Health Sciences Center, Memphis, TN 38104, United States
| | - Nivedita Lahiri
- Division of Rheumatology, Immunology and Allergy, Brigham Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Smruti R Mohanty
- Division of Gastroenterology and Hepatobiliary Disease, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY 11215, United States
| | - Jian Wu
- Department of Medical Microbiology, Key Laboratory of Molecular Virology, Fudan University School of Basic Medical Sciences, Shanghai 200032, China
| | - Tomasz I Michalak
- Molecular Virology and Hepatology Research Group, Division of BioMedical Sciences, Health Sciences Centre, Memorial University, St. John’s, NL A1B 3V6, Canada
| | - Sanjaya K Satapathy
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, University of Tennessee Health Sciences Center, Memphis, TN 38104, United States
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Onoe T, Tahara H, Tanaka Y, Ohdan H. Prophylactic managements of hepatitis B viral infection in liver transplantation. World J Gastroenterol 2016; 22:165-175. [PMID: 26755868 PMCID: PMC4698483 DOI: 10.3748/wjg.v22.i1.165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 11/11/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) is a considerably effective treatment for patients with end-stage hepatitis B virus (HBV)-related liver disease. However, HBV infection often recurs after LT without prophylaxis. Since the 1990s, the treatment for preventing HBV reinfection after LT has greatly progressed with the introduction of hepatitis B immunoglobulin (HBIG) and nucleos(t)ide analogues (NAs), resulting in improved patient survival. The combination therapy consisting of high-dose HBIG and lamivudine is highly efficacious for preventing the recurrence of HBV infection after LT and became the standard prophylaxis for HBV recurrence. However, mainly due to the high cost of HBIG treatment, an alternative protocol for reducing the dose and duration of HBIG has been evaluated. Currently, combination therapy using low-dose HBIG and NAs is considered as the most efficacious and cost-effective prophylaxis for post-LT HBV reinfection. Recently, NA monotherapy and withdrawal of HBIG from combination therapy, along with the development of new, potent high genetic barrier NAs, have provided promising efficacy, especially for low-risk recipients. This review summarizes the prophylactic protocol and their efficacy including prophylaxis of de novo HBV infection from anti-HBc antibody-positive donors. In addition, challenging approaches such as discontinuation of all prophylaxis and active immunity through hepatitis B vaccination are discussed.
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Ku W, Wang U, Nguyen MH. Efficacy and effectiveness of anti-HBV therapy with early withdrawal of HBIG prophylaxis to prevent HBV recurrence following liver transplantation. Expert Opin Biol Ther 2015; 15:665-77. [PMID: 25865452 DOI: 10.1517/14712598.2015.1025045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The traditional regimen for prophylaxis of hepatitis B recurrence post-liver transplantation is to use hepatitis B immune globulin (HBIG) along with oral antiviral therapy; however, it is unclear when it is safe to discontinue HBIG after certain time point and to maintain patients with only oral antiviral therapy. Several studies have suggested that maintenance with oral anti-hepatitis B virus (HBV) therapy following short-term or no HBIG following the immediate post-transplantation period may also be safe and effective in prevention of HBV recurrence. AREAS COVERED We reviewed relevant literature to determine the effectiveness of early withdrawal of HBIG after liver transplantation and its effect on prevention of HBV recurrence. We used PubMed to search for any studies that used HBIG-free or short-term HBIG protocols with continued anti-HBV therapy. Short-term is defined as 12 months or less, and it is an evolving concept as new data on shorter and shorter duration becomes available. Additionally, a mini-quantitative analysis of the studies was performed using studies that involved the use of entecavir and tenofovir as anti-HBV therapy with or without HBIG. EXPERT OPINION Patients who are considered low risk for HBV recurrence at the time of liver transplant may safely be able to utilize a short-term duration of HBIG with indefinite antiviral maintenance therapy afterwards, whereas high-risk patients will likely need long-term HBIG in combination with antiviral therapy.
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Affiliation(s)
- Winston Ku
- Stanford University Medical Center, Division of Gastroenterology and Hepatology , 750 Welch Rd, Suite #210, Palo Alto, CA 94304 , USA
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Varghese J, Sachan D, Reddy MS, Cherian T, Jothimani D, Venugopal K, Arikichenin O, Perumalla R, Narasimhan G, Shanmugam V, Vijaya S, Venkataraman J, Rela M. Hepatitis B immunoglobulin prophylaxis after liver transplantation: experience in a tertiary transplant centre. J Clin Exp Hepatol 2014; 4:209-13. [PMID: 25755562 PMCID: PMC4284215 DOI: 10.1016/j.jceh.2014.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 07/17/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Prophylaxis with hepatitis B immunoglobulin (HBIG) and nucleoside analogs can prevent hepatitis B virus (HBV) recurrence after liver transplant (LT). AIM To determine the efficacy and cost of maintaining immunoprophylaxis with HBIG and hyperimmune plasma (HIP) for 6 months after LT. MATERIAL & METHODS The study included 22 HBV related LT recipients who were on entecavir and either HBIG or HIP for 6 months. Post transplant HBIG or HIP dose and cost incurred towards prophylaxis were noted. The cost of 200 IU of HBIG at the time of study was Rs 8250/- (US Dollars 135) and that of 2000 IU of HIP was Rs 8000/- (USD 130.7). The loading and maintenance costs at end of 6 months were compared between the two groups. Response to HBIG and HIP was assessed by checking for HBsAg reactivity, anti HBs titer response and HBV DNA viral load. STATISTICAL ANALYSIS Median and range, Kruskal Wallis (KW) sign rank Sum Test and Correlation Coefficient (r2) was used for analysis. RESULTS Thirteen recipients received HBIG and 9 recipients HIP. The anti HBs response to HIP was significantly high compared to HBIG (KW Sign rank Sum test P < 0.05); titers remained high until the study period. Between 8 and 30 days, the titer achieved by both HBIG and HIP was similar (KW Sign rank Sum test not significant). Despite low anti HBs titer of <100 IU/L, none of the recipients on HBIG had HBsAg reactivity while 3 on HIP had transient HBsAg positivity. The total cost with HBIG was 13.9 times the cost of HIP. CONCLUSION HIP immunoprophylaxis in combination with entecavir achieves a high anti HBs titer at a significant low cost during anhepatic and loading phase. HBV reactivation rates with HBIG and HIP is low despite low anti HBs titer.
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Key Words
- ESLD, end-stage liver disease
- HBIG, hepatitis B immunoglobulin
- HBV recurrence
- HBV, hepatitis B virus
- HBsAg, hepatitis B surface antigen
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- HIP, hyper-immune plasma
- HIV, human immunodeficiency virus
- Hepatitis B virus
- KW, Kruskal Wallis
- LT, liver transplantation
- NA, nucleos(t)ide analogs
- USD, US Dollars
- anti HBs Ab, anti hepatitis B virus antibody
- hepatitis B immunoglobulin
- hyper-immune plasma
- liver transplantation
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Affiliation(s)
- Joy Varghese
- Department of Hepatology & Liver Transplantation, Institute of Liver Diseases & Transplantation, Global Hospitals & Health City, Chennai, India
| | - Deepti Sachan
- Department of Transfusion Medicine, Global Hospitals & Health City, Chennai, India
| | - Mettu S. Reddy
- Department of Liver Transplant & Hepato Biliary Surgery, Institute of Liver Diseases & Transplantation, Global Hospitals & Health City, Chennai, India
| | - Tom Cherian
- Department of Liver Transplant & Hepato Biliary Surgery, Institute of Liver Diseases & Transplantation, Global Hospitals & Health City, Chennai, India
| | - Dinesh Jothimani
- Department of Hepatology & Liver Transplantation, Institute of Liver Diseases & Transplantation, Global Hospitals & Health City, Chennai, India
| | - Kota Venugopal
- Department of Liver Transplant & Hepato Biliary Surgery, Institute of Liver Diseases & Transplantation, Global Hospitals & Health City, Chennai, India
| | - Olithselvan Arikichenin
- Department of Hepatology & Liver Transplantation, Institute of Liver Diseases & Transplantation, Global Hospitals & Health City, Chennai, India
| | - Rajasekar Perumalla
- Department of Liver Transplant & Hepato Biliary Surgery, Institute of Liver Diseases & Transplantation, Global Hospitals & Health City, Chennai, India
| | - Gomathy Narasimhan
- Department of Liver Transplant & Hepato Biliary Surgery, Institute of Liver Diseases & Transplantation, Global Hospitals & Health City, Chennai, India
| | - Vivekananthan Shanmugam
- Department of Liver Transplant & Hepato Biliary Surgery, Institute of Liver Diseases & Transplantation, Global Hospitals & Health City, Chennai, India
| | - Srinivasan Vijaya
- Department of Hepatology & Liver Transplantation, Institute of Liver Diseases & Transplantation, Global Hospitals & Health City, Chennai, India
| | - Jayanthi Venkataraman
- Department of Hepatology & Liver Transplantation, Institute of Liver Diseases & Transplantation, Global Hospitals & Health City, Chennai, India
- Address for correspondence: Dr. Jayanthi Venkataraman, Department of Gastroenterology and Hepatology, Global Hospitals & Health City, Chennai 600 100, India. Tel.: +91 44 2277700; fax: +91 44 22777100.
| | - Mohamed Rela
- Department of Liver Transplant & Hepato Biliary Surgery, Institute of Liver Diseases & Transplantation, Global Hospitals & Health City, Chennai, India
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Reddy MS, Varghese J, Venkataraman J, Rela M. Matching donor to recipient in liver transplantation: Relevance in clinical practice. World J Hepatol 2013; 5:603-611. [PMID: 24303088 PMCID: PMC3847943 DOI: 10.4254/wjh.v5.i11.603] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 10/23/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023] Open
Abstract
Achieving optimum outcomes after liver transplantation requires an understanding of the interaction between donor, graft and recipient factors. Within the cohort of patients waiting for a transplant, better matching of the donor organ to the recipient will improve transplant outcomes and benefit the overall waiting list by minimizing graft failure and need for re-transplantation. A PubMed search was conducted to identify published literature investigating the effects of donor factors such as age, gender, ethnicity, viral serology; graft factors such as size and quality, recipient factors such as age, size, gender and transplant factors such as major or minor blood group incompatibility and immunological factors. We also report technical and therapeutic modifications that can be used to manage donor-recipient mismatch identified from literature and the authors’ clinical experience. Multiple donor and recipient factors impact graft survival after liver transplantation. Appropriate matching based on donor-organ-recipient variables, modification of surgical technique and innovative peri-transplant strategies can increase the donor pool by utilizing grafts from marginal donors that are traditionally turned down.
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Yi NJ, Lee KW, Kong SY, Park KU, Lee KB, Hong G, Han SS, Park SJ, Suh KS. Outcome of various treatments for posttransplant hepatitis B virus recurrence. World J Surg 2013; 37:812-9. [PMID: 23344522 DOI: 10.1007/s00268-013-1914-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Currently, no treatment guidelines are available for posttransplant hepatitis B virus (HBV) recurrence. We retrospectively evaluated the rate of clearance of hepatitis B surface antigen (HBsAg) from serum according to various treatment regimens in two large Korean liver transplantation centers. METHODS Between 1996 and 2008, HBV recurred in 59 patients among 933 HBV liver recipients (6.3 %). Patients with HBV recurrence were divided into four groups according to their treatment: group L (lamivudine-based therapy n = 21) and group N [new nucleos(t)ide analogue (NA)-based therapy, n = 38]. Intravenous hepatitis B immunoglobulin (ivHBIG) had been simultaneously administered to 10 patients in group L and 26 patients in group N. The mean posttransplant follow-up duration and time to HBV recurrence were 69 (14-152) months and 37 (3-120) months. RESULTS Overall, 22 patients (37.3 %) showed seronegative conversion of HBsAg for a median 8 months after treatment (range 1-15 months). The seroclearance rate was significantly higher in group N (n = 20, 52.6 %) than in group L (n = 2, 9.5 %) (p < 0.000). The time to seroconversion did not differ between group L (7 months, range 5-16) and group N (7 months, range 1-15) (p = 0.428). Subgroup analysis showed that the HBsAg seroconversion rate was much higher for patients given combined ivHBIG and new NAs (15/26 patients, 58.0 %) than the others (p = 0.006). CONCLUSIONS Seroclearance of HBsAg could be achieved using new NAs in half of the patients after posttransplant HBV recurrence. Combined ivHBIG may add a synergistic effect to new NAs for clearing HBsAg.
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Affiliation(s)
- Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, 101 Daehak-ro, Chongro-gu, Seoul, 110-744, South Korea
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Siciliano M, Parlati L, Maldarelli F, Rossi M, Ginanni Corradini S. Liver transplantation in adults: Choosing the appropriate timing. World J Gastrointest Pharmacol Ther 2012; 3:49-61. [PMID: 22966483 PMCID: PMC3437446 DOI: 10.4292/wjgpt.v3.i4.49] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 06/27/2012] [Accepted: 07/08/2012] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is indicated in patients with acute liver failure, decompensated cirrhosis, hepatocellular carcinoma and rare liver-based genetic defects that trigger damage of other organs. Early referral to a transplant center is crucial in acute liver failure due to the high mortality with medical therapy and its unpredictable evolution. Referral to a transplant center should be considered when at least one complication of cirrhosis occurs during its natural history. However, because of the shortage of organ donors and the short-term mortality after liver transplantation on one hand and the possibility of managing the complications of cirrhosis with other treatments on the other, patients are carefully selected by the transplant center to ensure that transplantation is indicated and that there are no medical, surgical and psychological contraindications. Patients approved for transplantation are placed on the transplant waiting list and prioritized according to disease severity. Thus, the appropriate timing of transplantation depends on recipient disease severity and, although this is still a matter of debate, also on donor quality. These two variables are known to determine the “transplant benefit” (i.e., when the expected patient survival is better with, than without, transplantation) and should guide donor allocation.
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Affiliation(s)
- Maria Siciliano
- Maria Siciliano, Lucia Parlati, Federica Maldarelli, Stefano Ginanni Corradini, Department of Clinical Medicine, Division of Gastroenterology, Sapienza University of Rome, 00185 Rome, Italy
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Franciosi M, Caccamo L, De Simone P, Pinna AD, Di Costanzo GG, Volpes R, Scuderi V, Strignano P, Boccagni P, Burra P, Nicolucci A. Development and validation of a questionnaire evaluating the impact of hepatitis B immune globulin prophylaxis on the quality of life of liver transplant recipients. Liver Transpl 2012; 18:332-9. [PMID: 22139956 DOI: 10.1002/lt.22473] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To date, there is still a lack of instruments for specifically assessing the impact of anti-hepatitis B virus prophylaxis after liver transplantation (LT) on health-related quality of life (HRQOL) and treatment satisfaction. Focusing on the use of hepatitis B immune globulin (HBIG), we developed and validated the Immunoglobulin Therapy After Liver Transplantation Questionnaire (ITaLi-Q), which includes 41 items and covers 5 domains (side effects, positive and negative feelings, impact on the flexibility of daily activities, support, and satisfaction). The questionnaire was tested by 177 consecutive LT patients [71.8% were male, 38.4% were more than 60 years old, 58.8% were on intramuscular (IM) HBIG, and 41.2% were on intravenous (IV) HBIG]. A factor analysis confirmed the hypothesized structure, and a multitrait, multi-item analysis showed favorable psychometric characteristics for ITaLi-Q: item-scale correlations > 0.40 for all items but 1, high scaling success rates (>90% for all scales but 1), excellent internal consistency (Cronbach's α ≥ 0.8 for all scales), and good reproducibility (test-retest coefficient > 0.70 for all scales but 2). ITaLi-Q was able to discriminate between subgroups of patients according to their clinical and sociodemographic characteristics. In comparison with patients on IV HBIG, patients on IM HBIG reported significantly better HRQOL scores on the Flexibility (81.5 ± 21.4 versus 73.1 ± 24.2, P = 0.01) and Negative Feelings scales (90.1 ± 17.3 versus 85.4 ± 20.7, P = 0.04), but they reported worse HRQOL scores on the Side Effects scale (81.8 ± 22.8 versus 95.6 ± 7.4, P < 0.001). No differences were found between the route of HBIG administration and the Satisfaction, Positive Feelings, Impact, and Support scales. In conclusion, ITaLi-Q showed adequate psychometric characteristics and revealed that the route of HBIG administration has a significant impact on specific HRQOL domains beyond a patient's satisfaction.
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Affiliation(s)
- Monica Franciosi
- Department of Clinical Pharmacology and Epidemiology, Mario Negri Sud Consortium, Via Nazionale 8A, Santa Maria Imbaro, Italy.
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Wu TJ, Chen TC, Wang F, Chan KM, Soong RS, Chou HS, Lee WC, Yeh CT. Large fragment pre-S deletion and high viral load independently predict hepatitis B relapse after liver transplantation. PLoS One 2012; 7:e32189. [PMID: 22363813 PMCID: PMC3283733 DOI: 10.1371/journal.pone.0032189] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 01/23/2012] [Indexed: 12/18/2022] Open
Abstract
Hepatitis B virus (HBV) associated end-stage liver diseases are the leading causes of liver transplantation (LT) in Taiwan. Relapse of hepatitis B occurs after LT, raising the risk of graft failure and reducing patient survival. Although several oral antiviral agents have been approved for anti-HBV treatment, lamivudine (LAM) remained to be the most widely used preventive regimen in Taiwan. While several clinical predictors have been identified for hepatitis B relapse, the predictive roles of the histopathological characteristics in liver explants as well as the genotypic features of the viruses in pre-LT serum samples have not been assessed. Between September 2002 and August 2009, 150 consecutive hepatitis B surface antigen (HBsAg) positive patients undergoing LT were included for outcome analysis following assessment of the clinicopathological and virological factors prior to LT. Kaplan-Meier analyses discovered that pre-operative LAM treatment ≤3 months; membranous distribution and higher expression of tissue HBsAg in liver explants; preoperative viral load ≧106 copies/ml; and presence of large fragment (>100 base pairs) pre-S deletion (LFpreSDel) correlated significantly with hepatitis B relapse. Multivariate Cox regression analysis showed that the presence of LFpreSDel (P = 0.001) and viral load ≧106 copies/mL (P = 0.023) were independent predictors for hepatitis B relapse. In conclusion, besides high viral load, LFpreSDel mutation is an important independent predictor for hepatitis B relapse after LT. More aggressive preventive strategies should be applied for patients carrying these risk factors.
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Affiliation(s)
- Ting-Jung Wu
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Tse-Ching Chen
- Department of Pathology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Frank Wang
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kun-Ming Chan
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ruey-Shyang Soong
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hong-Shiue Chou
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wei-Chen Lee
- Division of Liver and Transplantation Surgery, Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- * E-mail: (CTY); (WCL)
| | - Chau-Ting Yeh
- Liver Research Center, Department of Hepato-Gastroenterology, Chang Gung Medical Center, Taoyuan, Taiwan
- * E-mail: (CTY); (WCL)
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Liver transplant outcomes in HIV-infected patients: a systematic review and meta-analysis with synthetic cohort. AIDS 2011; 25:777-86. [PMID: 21412058 DOI: 10.1097/qad.0b013e328344febb] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES The relative success of liver transplantation in those with HIV compared to HIV-uninfected individuals remains a point of intense debate. We aimed to evaluate the effectiveness of liver transplantation in HIV-hepatitis co-infected patients using a meta-analysis and individual patient data meta-analysis as a synthetic cohort. METHODS We searched MEDLINE via PubMed, EMBASE, Cochrane CENTRAL, AIDSLINE (inception to 2010), AMED, CINAHL, TOXNET, Development and Reproductive Toxicology, Hazardous Substances Databank, Psych-info and relevant conferences. We included cohort studies and individual case-reports evaluating survival of co-infected transplant patients. We abstracted data on cohort and case demographics and outcomes. We pooled cohorts using a random-effects analysis and created a synthetic cohort of cases using individual patient data. We confirmed this with the pooled cohort analysis. RESULTS We included 15 cohort studies and 49 case series with individual patient data. At 12 months, 84.4% [95% confidence interval (CI) 81.1-87.8%] of patients had survived. Within the HIV-infected population evaluated, HIV-hepatitis B virus (HBV) co-infection was associated with optimal survival. In an adjusted model, individuals positive for HBV were 8.28 (95% CI 2.26-30.33) times more likely to survive when compared to those without HBV. Further, individuals with an undetectable HIV viral load at the time of transplantation were 2.89 (95% CI 1.41-5.91) times more likely to survive when compared to those with detectable HIV viremia. Hepatitis C virus was not a predictor of patient survival when adjusted for by other key predictors [0.54 (95% CI 0.17-1.80)].
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Brock GN, Mostajabi F, Ferguson N, Carrubba CJ, Eng M, Buell JF, Marvin MR. Prophylaxis against de novo hepatitis B for liver transplantation utilizing hep B core (+) donors: does hepatitis B immunoglobulin provide a survival advantage? Transpl Int 2011; 24:570-81. [PMID: 21401727 DOI: 10.1111/j.1432-2277.2011.01236.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Donor liver allografts with positive serology for hepatitis B core antibody [HBc (+)] have been increasingly used for liver transplantation. However, the optimal prophylactic regimen to prevent development of de novo hepatitis B has not been determined. To evaluate this, we screened United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research (STAR) registry data for adult recipients of HBc (+) organs who were HBsAg (-), and evaluated the effects of using prophylactic anti-viral therapies (HBIG and lamivudine) on patient and graft survival. Out of a total cohort of 958 patients transplanted since 2004, 61 received HBIG alone, 116 received lamivudine alone, 66 both, 509 neither and 206 were missing this information. Based on several multivariable Cox regression models, patients receiving HBIG therapy-only were observed to have a statistically significant (approximately 70%) reduction in risk of mortality compared with patients receiving lamivudine-only therapy [HR=0.29, 95% CI (0.10, 0.86), P=0.026], and a nonstatistically significant reduction in risk of graft failure. However, no graft failures were attributed to de novo hepatitis B, suggesting that any improved graft/patient survival possibly associated with HBIG therapy occurs independently of de novo hepatitis B virus (HBV) reduction. While this study cannot prove that HBIG therapy is protective for graft and patient survival after liver transplantation, these findings do highlight the need to further examine and study prophylactic use in recipients of HBc (+) donors.
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Affiliation(s)
- Guy N Brock
- Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, KY, USA
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16
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Sevmis S, Aktas S, Zia H, Atiq A, Akbas E, Selcuk H, Karakayali H, Haberal M. Long-Term Results of Hepatitis B Immunoglobulin and Lamuvidine for Hepatitis B Prophylaxis After Liver Transplantation. Transplant Proc 2011; 43:598-600. [DOI: 10.1016/j.transproceed.2011.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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17
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Minemura M, Tokimitsu Y, Tajiri K, Nakayama Y, Kawai K, Kudo H, Hirano K, Atarashi Y, Yata Y, Yasumura S, Takahara T, Sugiyama T. Development of osteomalacia in a post-liver transplant patient receiving adefovir dipivoxil. World J Hepatol 2010; 2:442-6. [PMID: 21191520 PMCID: PMC3010514 DOI: 10.4254/wjh.v2.i12.442] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 10/11/2010] [Accepted: 10/18/2010] [Indexed: 02/06/2023] Open
Abstract
We report the case of a patient treated with living donor-related liver transplantation who suffered from osteomalacia during adefovir dipivoxil (ADV)-containing antiviral therapy for lamivudine-resistant hepatitis B virus infection. The patient had generalized bone pain, with severe hypophosphatemia after 20 mo of ADV therapy. Radiographic studies demonstrated the presence of osteomalacia. The peak plasma ADV level was 38 ng/mL after administration of ADV at 10 mg/d. It was also found that ADV affected the metabolism of tacrolimus, a calcineurin-inhibitor, and caused an increase in the plasma levels of tacrolimus. The disability was reversed with the withdrawal of ADV and with mineral supplementation. ADV can cause an elevation of plasma tacrolimus levels, which may be associated with renal dysfunction. High levels of ADV and tacrolimus can cause nephrotoxicity and osteomalacia. This case highlights the importance of considering a diagnosis of osteomalacia in liver transplantation recipients treated with both ADV and tacrolimus.
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Affiliation(s)
- Masami Minemura
- Masami Minemura, Yoshiharu Tokimitsu, Kazuto Tajiri, Yasuhiro Nakayama, Kengo Kawai, Hiroshi Kudo, Katsuharu Hirano, Yoshinari Atarashi, Yutaka Yata, Satoshi Yasumura, Terumi Takahara, Toshiro Sugiyama, Third Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan
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18
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Degertekin B, Han SHB, Keeffe EB, Schiff ER, Luketic VA, Brown RS, Emre S, Soldevila-Pico C, Reddy KR, Ishitani MB, Tran TT, Pruett TL, Lok ASF. Impact of virologic breakthrough and HBIG regimen on hepatitis B recurrence after liver transplantation. Am J Transplant 2010; 10:1823-33. [PMID: 20346062 PMCID: PMC2910807 DOI: 10.1111/j.1600-6143.2010.03046.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The availability of hepatitis B immune globulin (HBIG) and several oral antiviral therapies has reduced but not eliminated hepatitis B virus (HBV) recurrence. We aimed to determine the rate of HBV recurrence after orthotopic liver transplantation (OLT) in relation to virologic breakthrough pre-OLT and HBIG regimens post-OLT. Data from the NIH HBV-OLT database were analyzed. A total of 183 patients transplanted between 2001 and 2007 followed for a median of 42 months (range 1-81) post-OLT were studied. At transplant, 29% were hepatitis B e antigen (HBeAg) (+), 38.5% had HBV DNA > 5 log(10) copies/mL, 74% were receiving antiviral therapy. Twenty-five patients experienced virologic breakthrough before OLT. Post-OLT, 26%, 22%, 40% and 12% of patients received intravenous (IV) high-dose, IV low-dose, intramuscular low-dose and a finite duration of HBIG, respectively as maintenance prophylaxis. All but two patients also received antiviral therapy. Cumulative rates of HBV recurrence at 1 and 5 years were 3% and 9%, respectively. Multivariate analysis showed that listing HBeAg status and HBV DNA level at OLT were the only factors associated with HBV recurrence. In conclusion, low rates of HBV recurrence can be accomplished with all the HBIG regimens used when combined with antiviral therapy including patients with breakthrough pre-OLT as long as rescue therapy is administered pre- and post-OLT.
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Affiliation(s)
- Bulent Degertekin
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Emmet B. Keeffe
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, CA
| | | | | | | | | | | | | | | | - Tram T. Tran
- Cedars Sinai Medical Center, Los Angeles, CA, USA
| | | | - Anna S. F. Lok
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI,Corresponding author: Anna SF Lok, MD Division of Gastroenterology University of Michigan Medical Center 3912 Taubman Center, SPC 5362 Ann Arbor, MI 48109 Fax: 734--936-7024
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Bihl F, Russmann S, Gurtner V, Di Giammarino L, Pizzi-Bosman L, Michel M, Cerny A, Hadengue A, Majno P, Giostra E, Castelli D, Mentha G. Hyperimmune anti-HBs plasma as alternative to commercial immunoglobulins for prevention of HBV recurrence after liver transplantation. BMC Gastroenterol 2010; 10:71. [PMID: 20598161 PMCID: PMC2912239 DOI: 10.1186/1471-230x-10-71] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Accepted: 07/04/2010] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Hepatitis B immune globulins (HBIG) in combination with nucleos(t)ide analogues (NA) are effectively used for the prevention of hepatitis B virus (HBV) recurrence after liver transplantation (LT). However, associated treatment costs for HBIG are exceedingly high. METHODS Fresh frozen plasma obtained from blood donors with high anti-HBs levels (hyperimmune plasma, HIP) containing at least 4,500 IU anti-HBs was used as alternative treatment for HBV recurrence prophylaxis post-LT. RESULTS Twenty-one HBV-related LT recipients received HIP starting at transplantation, followed by long-term combination treatment with NA. Mean follow-up time was 4.5 years (range 0.5-12.6) and each patient received on average 8.2 HIP per year (range 5.8-11.4). Anti-HBs terminal elimination kinetic after HIP administration was 20.6 days (range 13.8-30.9), which is comparable to values reported for commercial HBIG products. All 21 patients remained free of HBV recurrence during follow-up and no transfusion-transmitted infection or other serious complication was observed. Seven patients developed reversible mild transfusion reactions. The cost for one HIP unit was US$140; average yearly HBIG treatment cost was US$1,148 per patient, as compared to US$25,000-100,000 for treatment with commercial HBIG. CONCLUSION The results of this study suggest that the use of HIP may be a useful and economical approach for the prevention of HBV recurrence post-LT if used in combination with NA. Additional prospective controlled studies in larger populations are needed to confirm these results.
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Affiliation(s)
- Florian Bihl
- Department of Gastroenterology and Hepatology, University Hospital of Geneva, Switzerland.
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Jiang L, Jiang LS, Cheng NS, Yan LN. Current prophylactic strategies against hepatitis B virus recurrence after liver transplantation. World J Gastroenterol 2009; 15:2489-99. [PMID: 19468999 PMCID: PMC2686907 DOI: 10.3748/wjg.15.2489] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Prophylactic strategies against hepatitis B virus (HBV) recurrence after liver transplantation (LT) are essential for patients with HBV-related disease. Before LT, lamivudine (LAM) was proposed to be down-graded from first- to second-line therapy. In contrast, adefovir dipivoxil (ADV) has been approved not only as first-line therapy but also as rescue therapy for patients with LAM resistance. Furthermore, combination of ADV and LAM may result in lower risk of ADV resistance than ADV monotherapy. Other new drugs such as entecavir, telbivudine and tenofovir, are probably candidates for the treatment of hepatitis-B-surface-antigen-positive patients awaiting LT. After LT, low-dose intramuscular hepatitis B immunoglobulin (HBIG), in combination with LAM, has been regarded as the most cost-effective regimen for the prevention of post-transplant HBV recurrence in recipients without pretransplant LAM resistance and rapidly accepted in many transplant centers. With the introduction of new antiviral drugs, new hepatitis B vaccine and its new adjuvants, post-transplant HBIG-free therapeutic regimens with new oral antiviral drug combinations or active HBV vaccination combined with adjuvants will be promising, particularly in those patients with low risk of HBV recurrence.
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Abstract
The transplantation outcome depends largely on the prevention of hepatitis B recurrence. The spontaneous risk of HBV reinfection exceeds 75%, but major advances in prophylaxis during the last 15 years have led to the control of post-transplant hepatitis B reinfection in more than 90% of HBV transplants. Treatment with hepatitis B immune globulins (HBIG) plays a major role in prophylaxis, either as monotherapy in non-replicating patients or in combination with antiviral drugs in replicating subjects. Although no standardized therapeutic protocols have been defined, at present the prevailing approach is to use high-dose intravenous HBIG in the immediate perioperative period (first week, induction phase) and to administer over the long term monthly fixed or on-demand doses of intravenous or intramuscular HBIG (maintenance therapy), in association with antiviral(s). Results have been excellent, yet different strategies of long-term prophylaxis have been proposed in order to simplify therapy and reduce costs. Long-term prophylaxis with antiviral(s) and low-dose intramuscular HBIG seems to be the most promising option; in stable patients, the combination with antiviral agents reduces the need of HBIG, in particular when using on-demand administration protocols and intramuscular HBIG has proven as effective and safe as intravenous preparations during the maintenance phase.
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22
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Saab S, Ham MY, Stone MA, Holt C, Tong M. Decision analysis model for hepatitis B prophylaxis one year after liver transplantation. Liver Transpl 2009; 15:413-20. [PMID: 19326401 DOI: 10.1002/lt.21712] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In patients receiving orthotopic liver transplantation, hepatitis B recurrence rates have decreased significantly with the use of various methods for prophylaxis. At present, a combination of hepatitis B immunoglobulin (HBIG) and lamivudine is the standard of care, resulting in recurrence rates of 0% to 11%. Recent data suggest that the addition of adefovir to lamivudine is successful in treating patients with recurrent hepatitis B infection. A Markov model was used to compare costs and outcomes of 2 strategies for hepatitis B prophylaxis 1 year after transplantation. The first consisted of prophylaxis with lamivudine and adefovir (strategy 1), whereas the second consisted of intramuscular HBIG and lamivudine (strategy 2) with the addition of adefovir in patients who subsequently developed hepatitis B recurrence. Patients who failed with adefovir and lamivudine were then treated with tenofovir and entecavir. 16.8% of liver transplant recipients had hepatitis B recurrence after 10 years of treatment with lamivudine and HBIG. The medical costs for strategy 1 and strategy 2 after 10 years of therapy were $151,819 and $166,246, respectively, and this resulted in cost savings of $14,427. The decision analysis model began 1 year after liver transplantation. A 1-way sensitivity analysis demonstrated that the model was most sensitive to cost changes of adefovir and HBIG injections as well as variations in the hepatitis B virus recurrence rate. The model was robust to costs of lamivudine, laboratory costs, administrative fees, and office visit fees. Our decision analysis model resulted in marked savings in costs with strategy 1 (lamivudine and adefovir), providing pharmacoeconomic support for the use of this strategy as first-line therapy in hepatitis B prophylaxis in liver transplant recipients 1 year after liver transplantation.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA.
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Luo Y, Lo CM, Cheung CK, Lau GK, Wong J. Hepatitis B virus-specific CD4 T cell immunity after liver transplantation for chronic hepatitis B. Liver Transpl 2009; 15:292-9. [PMID: 19243002 DOI: 10.1002/lt.21674] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cellular immunity plays an important role in the long-term control of hepatitis B virus (HBV) infection. We studied the changes in HBV-specific CD4 T cell immunity after orthotopic liver transplantation (OLT) for chronic hepatitis B under antiviral prophylaxis. T cell proliferation and interferon-gamma production in response to in vitro challenge with HBV-encoded antigens were tested in 40 OLT recipients without HBV recurrence and in 12 OLT recipients with HBV recurrence more than 1 year after transplantation, and they were compared to 40 subjects with chronic HBV infection and to 23 subjects with self-limited HBV infection. The frequency and magnitude of the HBV-specific CD4 T cell response were significantly lower in 40 OLT recipients with HBV clearance, but the T cell reactivity to mitogen (phytohemagglutinin) and recall antigen (tetanus toxoid) was maintained. In the 12 OLT recipients with HBV recurrence, however, the HBV-specific T cell immunity was enhanced to a level comparable to that of patients with chronic hepatitis B, and the level was dependent on the serum viral load. In conclusion, HBV-specific CD4 T cell immunity is antigen-driven and evanesces with viral clearance, hence providing a favorable milieu for reactivation once prophylaxis is withdrawn. The cellular immunity in recipients with recurrence is not significantly different from that of individuals with chronic hepatitis B.
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Affiliation(s)
- Ying Luo
- Department of Hepatobiliary Surgery, General Hospital of PLA, Beijing, China
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Akay S, Karasu Z. Hepatitis B immune globulin and HBV-related liver transplantation. Expert Opin Biol Ther 2008; 8:1815-22. [DOI: 10.1517/14712598.8.11.1815] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Kiyici M, Yilmaz M, Akyildiz M, Arikan C, Aydin U, Sigirli D, Nart D, Yilmaz F, Ozacar T, Karasu Z, Kilic M. Association Between Hepatitis B and Hepatocellular Carcinoma Recurrence in Patients Undergoing Liver Transplantation. Transplant Proc 2008; 40:1511-7. [DOI: 10.1016/j.transproceed.2008.03.156] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Accepted: 03/11/2008] [Indexed: 01/07/2023]
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Hooman N, Rifai K, Hadem J, Vaske B, Philipp G, Priess A, Klempnauer J, Tillmann HL, Manns MP, Rosenau J. Antibody to hepatitis B surface antigen trough levels and half-lives do not differ after intravenous and intramuscular hepatitis B immunoglobulin administration after liver transplantation. Liver Transpl 2008; 14:435-42. [PMID: 18383078 DOI: 10.1002/lt.21343] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hepatitis B immunoglobulin (HBIG) administration remains an essential component of standard reinfection prophylaxis after liver transplantation for hepatitis B virus-related liver disease. Previous studies have suggested that intramuscular (IM) HBIG administration compared to intravenous (IV) HBIG administration may be cost-effective and dose-saving. To compare antibody against hepatitis B surface antigen (anti-HBs) kinetics after IV HBIG administration versus IM HBIG administration, 24 patients received 2000 IU of HBIG every 6 weeks over a study period of 48 weeks in a crossover design. HBIG was started intravenously in 12 patients (group A) and intramuscularly in 12 patients (group B). After 4 doses, at week 24 HBIG administration was switched from IM to IV and vice versa. Anti-HBs kinetics of 22 patients were evaluated. Mean anti-HBs levels measured 2, 4, and 6 weeks after each HBIG administration did not differ significantly (480 +/- 166, 319 +/- 126, and 221 +/- 106 IU/L after IV administration versus 457 +/- 166, 310 +/- 147, and 218 +/- 112 IU/L after IM administration). Half-lives of anti-HBs decline (IV, 25.5 +/- 6.0 days, versus IM, 24.7 +/- 6.2 days) and area under the curve values from week 2 to 6 (IV, 9.4 +/- 3.6 IU*day/mL, versus IM, 9.0 +/- 3.9 IU*day/mL) also showed no significant difference. Variation of anti-HBs levels after IV HBIG administration versus IM HBIG administration was neither significantly different within patients (intraindividual variance) nor between patients (interindividual variance). However, intraindividual variance was lower than interindividual variance after IV (P < 0.05) and IM (P < 0.05) HBIG administration at every time point (2, 4, and 6 weeks). In conclusion, IV HBIG administration and IM HBIG administration are equally effective with respect to the crucial pharmacokinetic parameters. That is, IM HBIG is not dose-saving; however, it may be cost-effective if the price per unit is lower. Individualized dosing intervals should be further evaluated as a cost-effective alternative to fixed dosing schemes.
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Affiliation(s)
- Nazanin Hooman
- Department of Gastroenterology, Medizinische Hochschule Hannover, Hannover, Germany
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Akyildiz M, Karasu Z, Zeytunlu M, Aydin U, Ozacar T, Kilic M. Adefovir dipivoxil therapy in liver transplant recipients for recurrence of hepatitis B virus infection despite lamivudine plus hepatitis B immunoglobulin prophylaxis. J Gastroenterol Hepatol 2007; 22:2130-4. [PMID: 18031370 DOI: 10.1111/j.1440-1746.2006.04609.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Treatment of post-transplantation recurrence of hepatitis B virus (HBV) infection despite prophylaxis with hepatitis B immunoglobulin (HBIG) and lamivudine combination therapy is not easy. Because HBV reinfection has a severe course and could result in graft failure in liver transplant recipients, prompt medication is essential. Herein is reported the authors' experience with adefovir dipivoxil (AD) therapy in 11 liver transplant recipients who had HBV reinfection despite the administration of lamivudine and HBIG. METHOD Two-hundred and nine patients underwent liver transplantation (100 deceased donor liver transplantations [DDLT], 109 living donor liver transplantation [LDLT]) due to chronic hepatitis B infection between April 1997 and May 2005 in Ege University Medical School, Liver Transplantation Unit. Patients had prophylaxis with lamivudine and low-dose HBIG combination after liver transplantation. Treatment of recurrence consisted of AD 10 mg once a day and lamivudine 300 mg/daily and HBIG was discontinued in those patients. RESULTS In total there were 11 HBV recurrences: five occurred in DDLT recipients and six in LDLT recipients, at a median follow up of 18 months (range, 6-48 months). In one of 11 patients, pretransplant HBV-DNA and HBeAg were positive. Three patients had a severe course and one patient had fibrosing cholestatic hepatitis. After AD treatment, HBV-DNA level decreased in all patients and became negative in seven patients. Two patients died due to hepatocellular carcinoma recurrence after 12 and 14 months of follow up. Serum creatinine level increased mildly in one patient and no other side-effect was observed, and all patients continued therapy. CONCLUSION Adefovir dipivoxil is a safe, effective treatment option for post-transplant HBV recurrence even among patients with fibrosing cholestatic hepatitis caused by lamivudine-resistant HBV.
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Affiliation(s)
- Murat Akyildiz
- Department of Gastroenterology, Ege University Medical School, Bornova, Izmir, Turkey.
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Karasu Z, Akyildiz M, Kilic M, Zeytunlu M, Aydin U, Tekin F, Yilmaz F, Ozacar T, Akarca U, Ersoz G, Gunsar F, Ilter T, Lucey MR. Living donor liver transplantation for hepatitis B cirrhosis. J Gastroenterol Hepatol 2007; 22:2124-9. [PMID: 18031369 DOI: 10.1111/j.1440-1746.2006.04782.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Living donor liver transplantation (LDLT) has particular advantages for Turkey where hepatitis B virus (HBV) infection is the most common cause of cirrhosis, both because LDLT circumvents the difficulties encountered in the emerging world in providing deceased donor organs, and because it allows preemptive antiviral therapy. The aim of this study was to review one institution's experience with LDLT in patients with chronic HBV infection. METHODS A total of 109 patients with chronic HBV infection underwent LDLT between September 1999 and June 2005, of whom 40 were coinfected with hepatitis D virus and 23 had hepatocellular carcinoma. Antiviral prophylaxis was attempted in all, beginning prior to transplantation with lamivudine or adefovir, and continuing after transplantation with low dose intramuscular hyperimmune B immunoglobulin (HBIg) plus lamivudine or adefovir. RESULTS In a median follow up of 20 months (range 1-66 months), there was no donor mortality. One-year recipient survival was 90%, and in total 16 recipients died. None of the deaths was related to HBV. Recurrence of HBV infection was detected by reappearance of serum hepatitis B surface antigen in six patients (5.5%) at 5, 8, 12, 17, 34 and 46 months after transplantation, respectively. There was no influence of donor hepatitis B core antibody status on the likelihood of recurrence of HBV in the allograft. CONCLUSION The results indicate that LDLT with antiviral treatment and low dose HBIg provides excellent results for donors and recipients.
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Affiliation(s)
- Zeki Karasu
- Department of Gastroenterology, Ege University Medical School, Bornova, Izmir, Turkey
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Abstract
Advances in hepatitis B virus (HBV) antiviral prophylaxis have dramatically improved graft and patient survival for patients undergoing liver transplantation for hepatitis B related end-stage liver disease. In particular, the availability of hepatitis B immune globulin (HBIg) in combination with nucleos(t)ide analogues such as lamivudine and adefovir, have transformed outcomes. The availability of newer antivirals such as adefovir, tenofovir and entecavir either as monotherapy or in combination offer an increasing number of antiviral options. Despite these advances, significant challenges remain. Factors that affect the efficacy of anti-viral therapy include detectable HBV viraemia at the time of transplant and emergence of HBV mutants (especially in patients with prior exposure to lamivudine). HBV prophylaxis protocols are expensive especially with use of high-dose HBIg and newer nucleos(t)ide analogues. This review summarizes current HBV prophylaxis protocols and management of recurrent disease post-transplantation. There is an increasing need for individualization of therapy based on prior drug exposures, level of HBV DNA at time of transplantation and type of prophylaxis used.
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Affiliation(s)
- Carla S Coffin
- Department of Medicine, University of California at San Francisco, San Francisco, CA 94143, USA
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Neff GW, Kemmer N, Kaiser TE, Zacharias VC, Alonzo M, Thomas M, Buell J. Combination therapy in liver transplant recipients with hepatitis B virus without hepatitis B immune globulin. Dig Dis Sci 2007; 52:2497-500. [PMID: 17404847 DOI: 10.1007/s10620-006-9658-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Accepted: 10/17/2006] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Conventional therapy to prevent HBV recurrence in liver transplant (LTx) recipients consists of Hepatitis B Immune Globulin (HBIg). The aim of this review is to investigate the safety and efficacy of converting HBIg and LAM therapy to ADV and LAM therapy. METHODS A retrospective review involving all liver transplant patients with HBV maintained on HBIg and LAM therapy. Results collected included: gender, age, HBV serological and DNA status (COBAS AmpliScreen PCR-based testing). Serologic testing was done every three months. Patients were followed for drug reactions, therapy compliance, and immune suppression compliance. A cost benefit analysis was done for drug comparisons using United States currency values. RESULTS Patient demographics included: Male (n=6), Female (n=4), mean age 44 years (range 33 to 65). The mean length of follow up since therapy conversion (from HBIg and LMV to ADV and LMV) was 21 months (range 16 to 25 months). Serological status at time of conversion revealed that DNA status remained negative in all patients, HBsAg negative in 10/10, HB eAg (+) (5/10) and HBeAb (+)(5/10). None of the patients experienced an increase in transaminases while on dual ADV and LAM therapy. All patients were maintained on immune suppression monotherapy (tacrolimus) at 7-9 ng/mL. All patients reported compliance with the dual therapy and that they experienced no drug related side effects. Mean yearly costs for ADV and LAM was 7,235.00 United States dollars (range 6,550.00 to 8,225.00); while mean monthly costs for HBIg and LAM; 9225.00 (range 7205.00 to 12005.00). CONCLUSION The above results demonstrate beneficial effects of ADV and LAM in place of the current standard of HBIg and LAM therapy. Safety and short term results show nucleoside therapy is adequate at preventing HBV viral recurrence. Lastly, the economic benefit for ADV and LAM vastly outweighed the HBIg and LAM group.
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Affiliation(s)
- Guy W Neff
- Department of Medicine, Division of Digestive Diseases, University of Cincinnati, Cincinnati, Ohio 45267, USA.
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31
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Efficacy of hepatitis B immunoglobulin in relation to the gene polymorphisms of human leukocyte Fcγ receptor III (CD16) in Chinese liver transplant patients. Chin Med J (Engl) 2007. [DOI: 10.1097/00029330-200709020-00011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Bhat P, Anderson DA. Hepatitis B virus translocates across a trophoblastic barrier. J Virol 2007; 81:7200-7. [PMID: 17442714 PMCID: PMC1933314 DOI: 10.1128/jvi.02371-06] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2006] [Accepted: 04/08/2007] [Indexed: 12/20/2022] Open
Abstract
Mother-infant transmission of hepatitis B virus (HBV) accounts for up to 30% of worldwide chronic infections. The mechanism and high-risk period of HBV transmission from mother to infant are unknown. Although largely prevented by neonatal vaccination, significant transmission continues to occur in high-risk populations. It is unclear whether HBV can traverse an intact epithelial barrier to infect a new host. Transplacental transmission of a number of viruses relies on transcytotic pathways across placental cells. We wished to determine whether infectious HBV can traverse a polarized trophoblast monolayer. We used a human placenta-derived cell line, BeWo, cultured on membranes as polarized monolayers, to model the maternal-fetal barrier. We assessed the effects of placental maturity and maternal immunoglobulin on viral transport. Intracellular viral trafficking pathways were investigated by confocal microscopy. Free HBV (and infectious duck hepatitis B virus) transcytosed across trophoblastic cells at a rate of 5% in 30 min. Viral transport occurred in microtubule-dependent endosomal vesicles. Additionally, confocal microscopy showed that the internalized virus traverses a monensin-sensitive endosomal compartment. Differentiation of the cytotrophoblasts to syncytiotrophoblasts resulted in a 25% reduction in viral transcytosis, suggesting that placental maturity may protect the fetus. Virus translocation was also reduced in the presence of HBV immunoglobulin. We show for the first time that transcytosis of infectious hepadnavirus can occur across a trophoblastic barrier early in gestation, with the risk of transmission being reduced by placental maturity and specific maternal antibody. This study suggests a mechanism by which mother-infant transmission may occur.
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Affiliation(s)
- Purnima Bhat
- School of Biomedical Sciences, The University of Queensland, St. Lucia 4072, Australia.
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Cooper CL, DeForest J, Gill J, Lalonde R. Barriers preventing liver transplantation in Canadians with HIV-infection--perceptions of HIV specialists. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2007; 21:179-82. [PMID: 17377647 PMCID: PMC2657686 DOI: 10.1155/2007/769752] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Liver transplantation is a life-saving procedure with demonstrated utility. There are accumulating data indicating that this procedure is helpful in HIV-infected patients as well. Liver transplantation is currently largely unavailable to those living with HIV in Canada. Understanding the obstacles to this procedure is the first step to increasing access. Between August 2005 and November 2005, HIV physicians, one from each Canadian HIV Trials Network site, were asked to complete a quantitative questionnaire on adult liver transplant access and need. Forty-six per cent (16 of 35) of sites responded. A median 20% of the nearly 12,700 HIV patients followed at these sites had concurrent liver disease (20% caused by hepatitis C virus, 5% caused by hepatitis B virus and 5% were alcohol-related). On average, two patients per site were thought to be appropriate candidates for liver transplant evaluation. Eighty per cent of respondents anticipated increased need for liver transplantation over the next five years. Organ supply was universally identified as the chief obstacle to transplantation in patients with HIV. Other key issues included risk of hepatitis C virus reinfection and transplant surgical team willingness. Based on these data, it is believed that these issues should be the focus of efforts designed to increase access to transplantation in Canadians with end-stage liver disease and concurrent HIV.
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Prada Lobato J, Garrido López S, Catalá Pindado MA, García Pajares F. [The prophylaxis against post-liver-transplant hepatitis B re-infection]. FARMACIA HOSPITALARIA 2007; 31:30-7. [PMID: 17439311 DOI: 10.1016/s1130-6343(07)75708-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To review the prophylaxis against post-liver transplantation hepatitis B reinfection with anti-hepatitis B immunoglobulin and nucleoside analogues. METHOD A bibliographic search was carried out using Pubmed, entering the following key words: hepatitis B and liver transplantation and (hepatitis B hyperimmune globulin and lamivudine and adefovir dipivoxil) up to June 2006. The initial search was filtered using the terms clinical trial, randomized clinical trial and review. The data contained in selected studies were reviewed. RESULTS A total of 53 works were found. Prophylaxis with anti-HB immunoglobulin and lamivudine is the best strategy for avoiding recurrence of the hepatitis B virus in patients undergoing hepatic transplants; achieving very low reinfection rates (0-10%) with follow up periods of between 1-5 years. There is a great degree of variability (dose, duration and method of HBIg administration) in the prophylactic protocols reviewed. The use of low doses of anti-HB immunoglobulin (administered intravenously followed by intramuscular administration, or administered intramuscularly from the anhepatic stage), and lamivudine in patients who receive transplants with a low risk of recurrence, shows prophylactic efficacy comparable to the use of high doses of anti-HB immunoglobulin. Furthermore, it implies a considerable reduction in costs. CONCLUSIONS The availability of suitably designed clinical trials is required to design a more cost-effective protocol and reduce variability.
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Affiliation(s)
- J Prada Lobato
- Servicio de Farmacia, Hospital Universitario Río Hortega, Valladolid.
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35
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Rosenau J, Kreutz T, Kujawa M, Bahr MJ, Rifai K, Hooman N, Finger A, Michel G, Nashan B, Kuse ER, Klempnauer J, Tillmann HL, Manns MP. HBsAg level at time of liver transplantation determines HBsAg decrease and anti-HBs increase and affects HBV DNA decrease during early immunoglobulin administration. J Hepatol 2007; 46:635-44. [PMID: 17316869 DOI: 10.1016/j.jhep.2006.11.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2006] [Revised: 10/28/2006] [Accepted: 11/28/2006] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIMS Administration of hepatitis B immunoglobulin (HBIG) initially after liver transplantation of hepatitis B patients is considered important to prevent reinfection reliably. However, dosing schedules differ considerably between centers. We measured HBsAg, anti-HBs and HBV DNA kinetics to create a rational basis for dosing schemes. METHODS Thirteen patients (group A) received 10,000 IU HBIG in the anhepatic phase followed by 10,000 IU daily until HBsAg became negative, whereas five patients (group B) received 20,000 IU followed by 5000 IU every 30 min. RESULTS HBsAg levels at time of transplantation ranged from 0.12 to 12,990 IU/ml. Correlations between initial HBsAg and HBIG required to decrease HBsAg below 1 IU/ml were high in groups A and B (r=0.97, p<0.001; r=1.00, p<0.001), as were correlations between initial HBsAg and HBIG required to raise anti-HBs above 1000 IU/l (r=0.94, p<0.001; r=1.00, p<0.001). In 11 HBV DNA-positive patients, DNA levels became negative in seven, and dropped by 2.5 log10 (mean) in the other four patients during immunoglobulin administration. CONCLUSIONS In conclusion, required HBIG doses to decrease HBsAg and raise anti-HBs are determined by HBsAg levels at time of transplantation, not by HBV DNA levels. Shortened HBIG dosing intervals accelerate HBsAg decrease and anti-HBs increase. HBV DNA decreases rapidly during HBIG administration in most patients.
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Affiliation(s)
- Jens Rosenau
- Department of Gastroenterology, Hepatology and Endocrinology, Medizinische Hochschule Hannover, Hannover, Germany.
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36
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Yi NJ, Suh KS, Cho JY, Kwon CH, Lee KW, Joh JW, Lee SK, Kim SI, Lee KU. Recurrence of hepatitis B is associated with cumulative corticosteroid dose and chemotherapy against hepatocellular carcinoma recurrence after liver transplantation. Liver Transpl 2007; 13:451-8. [PMID: 17318862 DOI: 10.1002/lt.21043] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The incidence of hepatitis B (HB) recurrence after a liver transplantation has been reduced by prophylaxis with hepatitis B immunoglobulin (HBIG) and lamivudine. However, the long-term incidence of recurrence is <10%, and the factors associated with HB recurrence are unclear. This study analyzed the factors associated with HB recurrence in 203 recipients who underwent liver transplantation for HB in 3 major centers in Korea over 4 years. Eighty-five patients (41.9%) had a hepatocellular carcinoma (HCC). Preoperative active virus replicators with the HBeAg(+) (46.8%) and/or hepatitis B virus DNA(+) (39.4%) were observed in 136 patients (67.0%). The HB prophylaxis consisted of either HBIG monotherapy (n = 95, HBIG group) or combination therapy with lamivudine (n = 108, combination group). HB recurrence was defined as the appearance of the HBsAg. The follow-up period was 28.3 +/- 13.1 months (mean +/- SD). HB recurred in 21 patients (10.3%) after transplantation. The time from transplantation to recurrence was 16.3 +/- 9.4 months. Pre-LT DNA positivity was more prevalent in HBIG group (55.8%) than in the combination group (39.8%) (P = 0.015). However, the incidence of HB recurrence was similar in the HBIG (6.3%) and combination group (13.8%), as well as between the active replicators (12.5%) and nonreplicators (4.1%) (P < 0.05). There was a far higher incidence of HB recurrence in patients receiving corticosteroid pulse therapy (21.0% vs. 7.9%), patients who experienced HCC recurrence (31.3% vs. 8.6%), and patients receiving chemotherapy to prevent HCC recurrence (25.0% vs. 4.4%) (P < 0.05). The cumulative corticosteroid dose was higher in patients who experienced recurrence of HB (P = 0.002). Multivariable analysis confirmed the effect of the cumulative corticosteroid dose and chemotherapy to be risk factors. Liver transplantation for HB is safe, with low recurrence rates if adequate prophylaxis is used. However, the cumulative corticosteroid dose and the chemotherapy used for HCC were risk factors for HB recurrence, so careful monitoring for HB recurrence is needed in these patients.
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Affiliation(s)
- Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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37
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Rosenau J, Hooman N, Hadem J, Rifai K, Bahr MJ, Philipp G, Tillmann HL, Klempnauer J, Strassburg CP, Manns MP. Failure of hepatitis B vaccination with conventional HBsAg vaccine in patients with continuous HBIG prophylaxis after liver transplantation. Liver Transpl 2007; 13:367-73. [PMID: 17318859 DOI: 10.1002/lt.21003] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Hepatitis B vaccination after liver transplantation for hepatitis B-related liver disease has been investigated as an alternative strategy to reinfection prophylaxis with hepatitis B immunoglobulin (HBIG) with conflicting results. In most studies, HBIG treatment was discontinued before vaccination. An outstanding good response was achieved with vaccination under continuous HBIG administration using hepatitis B surface antigen (HBsAg)-based vaccine containing special adjuvants. Both, adjuvants and continuous HBIG administration have been discussed as crucial factors for good response. Twenty-four patients were vaccinated with conventional double dose recombinant vaccine containing 40 microg HBsAg up to 12 times at weeks 0, 2, 4 (cycle 1), 12, 14, 16 (cycle 2), 24, 26, 28 (cycle 3), and 36, 38, 40 (cycle 4). All patients received 2,000 IU HBIG every 6 weeks (4 times intravenously and 4 times intramuscularly). A significant response was defined as reconfirmed increase of anti-HBs-antigen (anti-HBs) unexplained by HBIG administration or lack of anti-HBs decrease below 100 IU/L after discontinuation of HBIG treatment after week 48. Only 2 of 24 patients (8.3%) responded significantly. Anti-HBs started to increase after the seventh vaccination (cycle 3, during intramuscular HBIG administration) in 1 patient and after 12th vaccination (cycle 4, during intravenous HBIG administration) in the other. Maximum anti-HBs levels were >1,000 IU/L in both patients and decreased significantly slower as compared to passive prophylaxis during follow-up. In conclusion, the conventional HBsAg vaccine failed to induce a significant humoral immune response in most patients despite continued HBIG treatment. Further studies should address the question, of whether the use of potent adjuvant systems results in higher response rates.
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Affiliation(s)
- Jens Rosenau
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
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Kim DY, Choi MS, Lee JH, Koh KC, Paik SW, Yoo BC, Joh JW, Lee SK, Rhee JC. Older donor allografts are associated with poor patient survival after living donor liver transplantation for hepatitis B virus-related liver diseases. Liver Int 2007; 27:260-7. [PMID: 17311622 DOI: 10.1111/j.1478-3231.2006.01403.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS The significance of donor age in living donor liver transplantation (LDLT) for hepatitis B virus (HBV) infection has not been fully evaluated. METHODS We analyzed the data of 136 patients who underwent LDLT for HBV-related liver diseases from January 1999 to April 2004. The recipients were divided into an older donor group (donor age > or = 40) and a younger donor group (donor age < 40). Posttransplant clinical outcomes and survival were compared between two groups, and predictors of survival after LDLT were evaluated. RESULTS Baseline characteristics were not different between the two groups, except for more number of female donors and higher positive donor anti-HBc rate in the older group. The frequencies of acute rejection and early mortality after transplantation were similar in the two groups. The long-term survival rates for the older donor group were significantly lower than those of the younger donor group (1-, 3-, 5-year survival rate = 84%, 75%, 46% vs. 92%, 86%, and 83%, P = 0.03). Multivariate analysis showed that older donor age was the only independent risk factor associated with survival after LDLT (HR = 2.3; 95% CI = 1.1-5.6, P = 0.04). CONCLUSIONS Our study suggests that older donor allografts would be associated with poor patient survival after LDLT for HBV-related liver diseases.
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Affiliation(s)
- Do Young Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Rosenau J, Hooman N, Rifai K, Solga T, Tillmann HL, Grzegowski E, Nashan B, Klempnauer J, Strassburg CP, Wedemeyer H, Manns MP. Hepatitis B virus immunization with an adjuvant containing vaccine after liver transplantation for hepatitis B-related disease: failure of humoral and cellular immune response. Transpl Int 2007; 19:828-33. [PMID: 16961775 DOI: 10.1111/j.1432-2277.2006.00374.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Long-term hepatitis B reinfection prophylaxis after liver transplantation with hepatitis B immunoglobulin (HBIG) and nucleoside analogues is expensive and inconvenient. Studies evaluating humoral immune responses to hepatitis B virus (HBV) vaccines showed conflicting results. Best results were achieved under continuous HBIG administration with an adjuvant-containing HBsAg vaccine. In the present study, 8 patients who had been HBsAg positive and HBV DNA negative prior to liver transplantation were immunized with HBsAg-vaccine containing the adjuvant 3-deacylated monophosphoryl-lipid-A. Vaccination was started after discontinuation of HBIG. Six vaccinations were administered at weeks 0, 2, 4, 12, 16 and 24. Humoral (anti-HBs titres) and cellular (enzyme-linked immunospot assay and fluorescence-activated cell sorting analysis) immune responses were studied. Only one of eight patients responded with a humoral immune response (maximum anti-HBs titre 561 U/l). In this patient, decrease of anti-HBs titre before vaccination was significantly slower than in the other seven patients and anti-HBs did not become negative before first vaccination. A T-cell response to HBsAg could not be detected in any of the patients. The responder was the only patient who showed a T-cell response to HBcAg. In conclusion, the adjuvant-containing vaccine did not induce a humoral or a detectable cellular immune response in most patients. Patient-related preconditions and concomitant HBIG administration should be further investigated as possible predictors for response.
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Affiliation(s)
- Jens Rosenau
- Department of Gastroenterology, Hepatology and Endocrinology, Medizinische Hochschule Hannover, Hannover, Germany.
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Zöllner B, Feucht HH, Sterneck M, Schäfer H, Rogiers X, Fischer L. Clinical reactivation after liver transplantation with an unusual minor strain of hepatitis B virus in an occult carrier. Liver Transpl 2006; 12:1283-9. [PMID: 16868945 DOI: 10.1002/lt.20858] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hepatitis B virus (HBV) DNA is detectable in a number of liver transplant candidates who are negative for hepatitis B surface antigen (HBsAg). After liver transplantation (LT), such patients may have molecular and/or serologic evidence of HBV replication. However, clinical disease from reactivation of occult HBV infection after LT has not been described. We report a patient who underwent LT for cryptogenic cirrhosis and had to be retransplanted twice for hepatic artery thrombosis. The patient was negative for HBsAg and positive for anti-hepatitis B core (HBc) and anti-HBs before all LT procedures and developed acute hepatitis B shortly after receiving the third graft. The HBV strain isolated at that time exhibited an unusual in frame insertion of a CAG motif within the HBV polymerase (HBV(INS+)). HBV(INS+) was detected retrospectively as a minor species in pretransplantation sera and the explanted native liver by insertion-specific polymerase chain reaction. This case in an occult HBV carrier shows that clinically apparent, endogenous reinfection of the graft may occur with minor HBV variants that are not detectable in pretransplantation samples by standard diagnostic procedures. This has implications for the analysis of sources of acute hepatitis B in patients after LT and possibly for consideration of antiviral prophylaxis in anti-HBc/anti-HBs/HBV DNA-positive patients.
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Affiliation(s)
- Bernhard Zöllner
- Institute of Infectious Diseases, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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Montalbano M, Neff GW. Management of recurrent viral hepatitis B and C after liver transplantation. Curr Gastroenterol Rep 2006; 8:60-6. [PMID: 16510036 DOI: 10.1007/s11894-006-0065-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Liver transplant teams are often faced with the challenges of managing viral recurrence after liver transplantation. Hepatitis C virus (HCV) remains the most challenging viral disease in the transplant community. Strategies to prevent and delay viral recurrence have slowly developed over the past 5 years. Hepatitis B virus (HBV), previously a contraindication for liver transplantation due to recurrence and cholestasis with allograft failure, is now one of the more favorable indications for liver transplantation as a result of current therapeutic options. This review investigates the up-to-date information on treatment outcomes for HCV and HBV in the period following liver transplant.
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Affiliation(s)
- Marzia Montalbano
- University of Cincinnati, 231 Albert Sabin Way, MSB Room 6560, Cincinnati, OH 45267-0595, USA
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Xia NX, Fu ZR, Qiu BA, Wang ZX, Li XX, Bai G, Yang YX, Wang K. Low-dose intra-muscular hepatitis B immunoglobulin combined with lamivudine for long-term prophylaxis of hepatitis B recurrence after liver transplantation. Shijie Huaren Xiaohua Zazhi 2006; 14:1288-1293. [DOI: 10.11569/wcjd.v14.i13.1288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy of long-term, low-dose intra-muscular hepatitis B immunoglobulin (HBIg) combined with lamivudine (LAM) in patients who received orthotopic liver transpl-ants (OLT) and have been followed up for acute or chronic HBV-related end-stage liver disease.
METHODS: The liver transplantation recipients (n = 173) who have been followed up and received antiviral prophylaxis post-OLT were divided into 3 sub-groups according to their post-OLT antiviral therapy, which were group A (LAM monotherapy, n = 2), group B (HBIg and LAM therapy, n = 168) and group C (HBIg and ADF therapy n = 3). All the patients received LAM treatment for 1 or 2 wk ahead of OLT. Either LAM (100 mg) or ADF (adefovir dipivoxil, 10 mg) was administered orally every day. HBIg were administered intravenously during the first post-operative week (total 5000 or 10 000 U according to HBV copies/L pre-operative) and intramuscularly thereafter (400 U per time, the interval can be adjusted according to HBsAb titer in the blood) to maintain an HBsAb titer > 300 U/L within 1 mo, > 200 U/L between 2-3 mo and > 100 U/L beyond 3 mo after operation. Mean follow-up period was 20.8 ± 14 mo. The periodical investigation for the liver function, the serological HBV and the analyses of liver tissues by immunohistochemistry were performed. The recurrent HB and the death suffered from it were recorded and analyzed in this research. The recurrence rates of HBV infection between UCLA and our institute were statistically analyzed.
RESULTS: Four patients experienced HBV recurrence overall. One patient in group A experienced HBV recurrence (1 week after OLT) and positive HBV DNA (2 mo after OLT) associated with an increase in serum alanine aminotransferase. The treatment resistance of LAM was defined and the recipient died of the multiple organ failure 8 mo after OLT. Recurrent HBV appeared in 3 patients, whose HBV DNA levels in the pre-OLT blood were more than 108 copies/L, in group B (12 d, 12 mo and 1.5 mo after OLT respectively). The pre- and post-operative HBeAg and HBV DNA were always positive in the first case whose blood HBsAb titer was far lower than programming effective one. The treatment resistance of HBIg was defined and the patient died of fulminant hepatitis 11 mo after OLT. The second case became an HBsAg carrier after HBV recurrence and was dead due to tumor recurrence 15 mo after OLT. The third case was fine with the treatment of HBIg combined with ADF and was negative for HBsAg after 5.5 mo. The HBV mutation might exist in both of the second and third case. None of group C had HBV recurrence. The HBV recurrence rate under the prophylaxis of HBIg combined with LAM was 1.8% (3/168). Intra-muscular HBIg was tolerated well in all the cases. The study showed no difference between UCLA and our institute (χ2 = 0.280 37), and the expenditure was 3000-4000 US dollars per year.
CONCLUSION: The low-dose intra-muscular HBIg combined with LAM is efficacious in the long-term prophylaxis of hepatitis B recurrence after OLT. The total expenditure of prophylaxis is lower. ADF shows efficacy against the HBV-YMDD lamivudine-resistant mutation and may be a more efficacious agent for the prophylaxis of HBV recurrence after OLT.
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Dan YY, Wai CT, Yeoh KG, Lim SG. Prophylactic strategies for hepatitis B patients undergoing liver transplant: a cost-effectiveness analysis. Liver Transpl 2006; 12:736-46. [PMID: 16628682 DOI: 10.1002/lt.20685] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatitis B immunoglobulin with lamivudine prophylaxis (LAM/HBIG) is effective in preventing Hepatitis B (HBV) recurrence posttransplant but is expensive and inconvenient. Lamivudine-resistant HBV, which has limited the usefulness of lamivudine monoprophylaxis in transplant, can now be effectively controlled with adefovir dipivoxil. We performed a cost-effectiveness analysis on the strategies of lamivudine prophylaxis with adefovir rescue(LAM/ADV) compared to combination LAM/intravenous fixed high-dose HBIG prophylaxis(LAM/ivHBIG) or LAM/intramuscular HBIG prophylaxis(LAM/imHBIG). Markov modeling was performed with analysis from societal perspective. Probability rates were derived from systematic review of the literature and cost taken from MEDICARE database. Outcome measures were incremental cost-effectiveness ratio(ICER) and cost to prevent each HBV recurrence and death. Analysis was performed at 5 years posttransplant as well as at end of life expectancy (15 years). Combination LAM/ivHBIG cost an additional USD562,000 at 15 years, while LAM/imHBIG cost an additional USD139,000 per patient compared to LAM/ADV. Although there is an estimated increase in recurrence of 53% with LAM/ADV and 7.6% increased mortality at the end of life expectancy (15 years), the ICER of LAM/ivHBIG over LAM/ADV treatment is USD760,000 per quality-adjusted life-years and for LAM/imHBIG, USD 188,000. Cost-effectiveness is most sensitive to cost of HBIG. Lamivudine prophylaxis with adefovir dipivoxil salvage offers the more cost-effective option for HBV patients undergoing liver transplant but with higher recurrence and death rate using a model that favors LAM/HBIG. Lowering the cost of HBIG maintenance will improve cost-effectiveness of LAM/HBIG strategy. In conclusion, a tailored approach based on individual risks will optimize the cost-benefit of HBV transplant prophylaxis.
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Affiliation(s)
- Yock Young Dan
- Department of Gastroenterology, National University Hospital, Singapore
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Eckert V, Struff WG. Hepatitis B: Where Are We Today? Transfus Med Hemother 2006. [DOI: 10.1159/000093298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Murray KF, Carithers RL. AASLD practice guidelines: Evaluation of the patient for liver transplantation. Hepatology 2005; 41:1407-32. [PMID: 15880505 DOI: 10.1002/hep.20704] [Citation(s) in RCA: 498] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Karen F Murray
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA 98195-6174, USA
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Marzano A, Gaia S, Ghisetti V, Carenzi S, Premoli A, Debernardi-Venon W, Alessandria C, Franchello A, Salizzoni M, Rizzetto M. Viral load at the time of liver transplantation and risk of hepatitis B virus recurrence. Liver Transpl 2005; 11:402-9. [PMID: 15776431 DOI: 10.1002/lt.20402] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatitis B virus (HBV) recurrence after liver transplantation is significantly reduced by prophylaxis with hepatitis B immune globulins (HBIG) or antiviral drugs in nonreplicating patients and by the combination of both drugs in replicating patients. However, the load of HBV DNA, which defines replicating status in patients undergoing liver transplantation, remains unclear. This study analyzes the correlation between the viral load, tested with a single amplified assay, at the time of liver transplantation, and the risk of hepatitis B recurrence in 177 HBV carriers who underwent transplantation in a single center from 1990 to 2002. Overall, HBV relapsed after surgery in 15 patients (8.5%) with a 5- and 8-year actuarial rate of recurrence of 8% and 21%, respectively. After liver transplantation hepatitis B recurred in 9% of 98 selected subjects treated only with immune globulins and in 8% of 79 viremic patients who received immune globulins and lamivudine (P = NS). A linear correlation was observed between recurrence and viral load at the time of surgery. In transplant patients with HBV DNA higher than 100,000 copies/mL, 200-99,999 copies/mL, and DNA undetectable by amplified assay, hepatitis B recurred in 50%, 7.5%, and 0% of patients, respectively. Overall, a viral load higher than 100,000 copies/mL at the time of liver transplantation was significantly associated with hepatitis B recurrence (P = .0003). In conclusion, spontaneous or antiviral-induced HBV DNA viral load at the time of surgery classifies the risk of HBV recurrence after liver transplantation and indicates the best prophylaxis strategy.
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Affiliation(s)
- Alfredo Marzano
- Department of Gastroenterology, San Giovanni Battista Hospital, Turin, Italy.
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Neff GW, O'brien CB, Nery J, Shire N, Montalbano M, Ruiz P, Nery C, Safdar K, De Medina M, Tzakis AG, Schiff ER, Madariaga J. Outcomes in liver transplant recipients with hepatitis B virus: resistance and recurrence patterns from a large transplant center over the last decade. Liver Transpl 2004; 10:1372-8. [PMID: 15497163 DOI: 10.1002/lt.20277] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Hepatitis B virus (HBV) recurrence following liver transplantation (LTx) has been controllable primarily with the use of hepatitis B immune globulin (HBIg) and lamivudine (LAM). However, HBV resistance to LAM and/or HBIg has become an increasing problem prompting the use of newer antiviral agents. The purpose of our study was to investigate the association between therapy, HBV breakthrough, and allograft / patient survival in HBV-positive liver transplant recipients. We performed a retrospective review of the medical records of patients that were transplanted for HBV from June 1994 to May 2003. A total of 92 patients, positive for either hepatitis B surface antigen (HBsAg) or HBV deoxyribonucleic acid (DNA) pretransplant, received LAM monotherapy or HBIg (6 months) plus LAM therapy post-liver transplant. HBV breakthrough post-LTx was noted in 14 patients. All patients had detectable HBV DNA prior to liver transplantation; none of the patients that were HBV DNA negative prior to transplant had detectable HBV DNA posttransplant. Of these 14, 9 patients (64%) were switched from LAM to adefovir dipivoxil (ADF) and 5 patients (36%) to tenofovir disoproxil fumarate (TNV). In conclusion, pre-LTx HBV viremia should be considered in planning post-LTx prophylaxis. Trials to evaluate oral antiviral agents in combination with or without HBIg therapy are needed.
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Affiliation(s)
- Guy W Neff
- Center for Liver Diseases, Department of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA.
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Akay S, Karasu Z, Akyildiz M, Tokat Y. Adefovir treatment in posttransplant hepatitis B virus infection resistant to lamivudine plus hepatitis B virus immunoglobulin. Transplant Proc 2004; 36:2768-70. [PMID: 15621144 DOI: 10.1016/j.transproceed.2004.09.062] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Failure of prophylaxis for hepatitis B virus (HBV) recurrence in liver transplant patients with HBV immunoglobulin (HBIG) or lamivudine or both can be associated with rapid development of liver failure. Some of these patients develop a devastating clinicopathological state characterized by jaundice and rapidly progressive liver failure or fibrosing cholestatic hepatitis. We present two liver transplant recipients who experienced HBV recurrence while they were under lamivudine and HBIG prophylaxis. One of them had finding of severe HBV infection; the other, fibrosing cholestatic hepatitis. After commencing adefovir dipivoxil both patients showed improvements in clinical status and laboratory data. At month 4 of treatment, HBV DNA values became negative and liver function tests almost normalized. In addition, in one case showed HBs ag/anti-HBs seroconversion. When failure of prophylaxis with lamivudine and HBIG occurs, adefovir dipivoxil should be considered to be a safe and effective choice for recurrent HBV infections in liver transplant patients.
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Affiliation(s)
- S Akay
- Department of Gastroenterology, Ege University, Izmir 35040, Turkey.
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Beckebaum S, Cicinnati VR, Gerken G, Broelsch CE. Management of chronic hepatitis B in the liver transplant setting. Transplant Rev (Orlando) 2004. [DOI: 10.1016/j.trre.2004.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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