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Hamdi M, Elmowafy E, Abdel-Bar HM, ElKashlan AM, Al-Jamal KT, Awad GAS. Hyaluronic acid-entecavir conjugates-core/lipid-shell nanohybrids for efficient macrophage uptake and hepatotropic prospects. Int J Biol Macromol 2022; 217:731-747. [PMID: 35841964 DOI: 10.1016/j.ijbiomac.2022.07.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 11/05/2022]
Abstract
Drug covalently bound to polymers had formed, lately, platforms with great promise in drug delivery. These drug polymer conjugates (DPC) boosted drug loading and controlled medicine release with targeting ability. Herein, the ability of entecavir (E) conjugated to hyaluronic acid (HA) forming the core of vitamin E coated lipid nanohybrids (EE-HA LPH), to target Kupffer cells and hepatocyte had been proved. The drug was associated to HA with efficiency of 93.48 ± 3.14 % and nanohybrids loading of 22.02 ± 2.3 %. DiI labelled lipidic nanohybrids improved the macrophage uptake in J774 cells with a 21 day hepatocytes retention post intramuscular injection. Finally, in vivo biocompatibility and safety with respect to body weight, organs indices and histopathological alterations were demonstrated. Coating with vitamin E and conjugation of E to HA (a CD44 ligand), could give grounds for prospective application for vectored nano-platform in hepatitis B.
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Affiliation(s)
- Mohamed Hamdi
- Department of Pharmaceutics, Faculty of Pharmacy, University of Sadat City, Egypt
| | - Enas Elmowafy
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Ain Shams University, Egypt
| | - Hend Mohamed Abdel-Bar
- Department of Pharmaceutics, Faculty of Pharmacy, University of Sadat City, Egypt; Institute of Pharmaceutical Science, Faculty of Life Sciences & Medicine, King's College London, United Kingdom.
| | - Akram M ElKashlan
- Department of Biochemistry, Faculty of Pharmacy, University of Sadat City, Egypt
| | - Khuloud T Al-Jamal
- Institute of Pharmaceutical Science, Faculty of Life Sciences & Medicine, King's College London, United Kingdom
| | - Gehanne A S Awad
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Ain Shams University, Egypt
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2
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Bacterial and Viral Infections in Liver Transplantation: New Insights from Clinical and Surgical Perspectives. Biomedicines 2022; 10:biomedicines10071561. [PMID: 35884867 PMCID: PMC9313066 DOI: 10.3390/biomedicines10071561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/11/2022] [Accepted: 06/27/2022] [Indexed: 01/03/2023] Open
Abstract
End-stage liver disease patients undergoing liver transplantation are prone to develop numerous infectious complications because of immunosuppression, surgical interventions, and malnutrition. Infections in transplant recipients account for the main cause of mortality and morbidity with rates of up to 80%. The challenges faced in the early post-transplant period tend to be linked to transplant procedures and nosocomial infections commonly in bloodstream, surgical, and intra-abdominal sites. Viral infections represent an additional complication of immunosuppression; they can be donor-derived, reactivated from a latent virus, nosocomial or community-acquired. Bacterial and viral infections in solid organ transplantation are managed by prophylaxis, multi-drug resistant screening, risk assessment, vaccination, infection control and antimicrobial stewardship. The aim of this review was to discuss the epidemiology of bacterial and viral infections in liver transplants, infection control issues, as well as surgical frontiers of ex situ liver perfusion.
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Fung J. Management of chronic hepatitis B before and after liver transplantation. World J Hepatol 2015; 7:1421-1426. [PMID: 26052387 PMCID: PMC4450205 DOI: 10.4254/wjh.v7.i10.1421] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 01/29/2015] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation remains the only curative option for eligible patients with complications of chronic hepatitis B (CHB) infection, including severe acute hepatitis flares, decompensated cirrhosis, and hepatocellular carcinoma. In general, all patients with CHB awaiting liver transplantation should be treated with oral nucleos(t)ide analogs (NAs) with high barriers to resistance to prevent potential flares of hepatitis and reduce disease progression. After liver transplantation, lifelong antiviral therapy is also required to prevent graft hepatitis, which may lead to subsequent graft loss. Although combination therapy using NA and hepatitis B immune globulin (HBIG) has been the regimen most widely adopted for over a decade, recent studies have demonstrated that newer NAs with low rates of resistance are effective in preventing graft hepatitis even without the use of HBIG, achieving excellent long term outcome. For patients without pre-existing resistant mutations, monotherapy with a single NA has been shown to be effective. For those with resistant strains, a combination of nucleoside analog and nucleotide analog should be used. To date, clinical trials using therapeutic vaccination have shown suboptimal response, as CHB patients likely have an immune deficit against HBV epitopes. Future strategies include targeting different sites of the hepatitis B replication cycle and restoring the host immunity response to facilitate complete viral eradication.
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Hulstaert E, Verhelst X, Geerts A, Van Vlierberghe H. Intramuscular hepatitis B immunoglobulins for reinfection control after liver transplantation: a cost-saving alternative. J Comp Eff Res 2015; 4:259-265. [DOI: 10.2217/cer.15.4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Aim: We explore the effectiveness and cost–effectiveness of intramuscular versus intravenous hepatitis B immunoglobulins (HBIG-IV vs HBIG-IM) to prevent reinfection with the hepatitis B virus after orthotopic liver transplantation. Patients & methods: Overall, 14 patients had orthotopic liver transplantation in 2003–2013 at Ghent University Hospital for HBV-related liver disease. On average 32 months after transplantation patients switched from high-dose HBIG-IV to low-dose HBIG-IM, always in combination with a nucleos(t)ide analog. Results: Seven patients were switched so far. No significant differences between HBIG-IV and HBIG-IM were found in HBsAg and hepatitis B virus-DNA. Conclusion: Switching patients from HBIG-IV to HBIG-IM can be done safely if well monitored. Net yearly savings for the healthcare payer were €5000 for each patient switched to HBIG-IM.
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Affiliation(s)
- Eva Hulstaert
- Department of Hepatology, University Hospital Ghent, De Pintelaan 185, B9000 Ghent, Belgium
| | - Xavier Verhelst
- Department of Hepatology, University Hospital Ghent, De Pintelaan 185, B9000 Ghent, Belgium
| | - Anja Geerts
- Department of Hepatology, University Hospital Ghent, De Pintelaan 185, B9000 Ghent, Belgium
| | - Hans Van Vlierberghe
- Department of Hepatology, University Hospital Ghent, De Pintelaan 185, B9000 Ghent, Belgium
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Jin JF, Zhu LL, Chen M, Xu HM, Wang HF, Feng XQ, Zhu XP, Zhou Q. The optimal choice of medication administration route regarding intravenous, intramuscular, and subcutaneous injection. Patient Prefer Adherence 2015; 9:923-42. [PMID: 26170642 PMCID: PMC4494621 DOI: 10.2147/ppa.s87271] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Intravenous (IV), intramuscular (IM), and subcutaneous (SC) are the three most frequently used injection routes in medication administration. Comparative studies of SC versus IV, IM versus IV, or IM versus SC have been sporadically conducted, and some new findings are completely different from the dosage recommendation as described in prescribing information. However, clinicians may still be ignorant of such new evidence-based findings when choosing treatment methods. METHODS A literature search was performed using PubMed, MEDLINE, and Web of Sciences™ Core Collection to analyze the advantages and disadvantages of SC, IV, and IM administration in head-to-head comparative studies. RESULTS "SC better than IV" involves trastuzumab, rituximab, antitumor necrosis factor medications, bortezomib, amifostine, recombinant human granulocyte-macrophage colony-stimulating factor, granulocyte colony-stimulating factor, recombinant interleukin-2, immunoglobulin, epoetin alfa, heparin, and opioids. "IV better than SC" involves ketamine, vitamin K1, and abatacept. With respect to insulin and ketamine, whether IV has advantages over SC is determined by specific clinical circumstances. "IM better than IV" involves epinephrine, hepatitis B immu-noglobulin, pegaspargase, and some antibiotics. "IV better than IM" involves ketamine, morphine, and antivenom. "IM better than SC" involves epinephrine. "SC better than IM" involves interferon-beta-1a, methotrexate, human chorionic gonadotropin, hepatitis B immunoglobulin, hydrocortisone, and morphine. Safety, efficacy, patient preference, and pharmacoeconomics are four principles governing the choice of injection route. Safety and efficacy must be the preferred principles to be considered (eg, epinephrine should be given intramuscularly during an episode of systemic anaphylaxis). If the safety and efficacy of two injection routes are equivalent, clinicians should consider more about patient preference and pharmacoeconomics because patient preference will ensure optimal treatment adherence and ultimately improve patient experience or satisfaction, while pharmacoeconomic concern will help alleviate nurse shortages and reduce overall health care costs. Besides the principles, the following detailed factors might affect the decision: patient characteristics-related factors (body mass index, age, sex, medical status [eg, renal impairment, comorbidities], personal attitudes toward safety and convenience, past experience, perception of current disease status, health literacy, and socioeconomic status), medication administration-related factors (anatomical site of injection, dose, frequency, formulation characteristics, administration time, indication, flexibility in the route of administration), and health care staff/institution-related factors (knowledge, human resources). CONCLUSION This updated review of findings of comparative studies of different injection routes will enrich the knowledge of safe, efficacious, economic, and patient preference-oriented medication administration as well as catching research opportunities in clinical nursing practice.
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Affiliation(s)
- Jing-fen Jin
- Division of Nursing, Division of Nursing, Zhejiang University, Hangzhou, People’s Republic of China
| | - Ling-ling Zhu
- VIP Care Ward, Division of Nursing, Zhejiang University, Hangzhou, People’s Republic of China
| | - Meng Chen
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Hui-min Xu
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Hua-fen Wang
- Division of Nursing, Division of Nursing, Zhejiang University, Hangzhou, People’s Republic of China
| | - Xiu-qin Feng
- Division of Nursing, Division of Nursing, Zhejiang University, Hangzhou, People’s Republic of China
| | - Xiu-ping Zhu
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Quan Zhou
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
- Correspondence: Quan Zhou, Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road No 88, Shangcheng District, Hangzhou 310009, Zhejiang Province, People’s Republic of China, Tel +86 571 8778 4615, Fax +86 571 8702 2776, Email
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Ghaziani T, Sendi H, Shahraz S, Zamor P, Bonkovsky HL. Hepatitis B and liver transplantation: molecular and clinical features that influence recurrence and outcome. World J Gastroenterol 2014; 20:14142-55. [PMID: 25339803 PMCID: PMC4202345 DOI: 10.3748/wjg.v20.i39.14142] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 04/29/2014] [Accepted: 05/25/2014] [Indexed: 02/07/2023] Open
Abstract
Hepatitis B virus (HBV) continues to be a major cause of morbidity and mortality worldwide. It is estimated that about 350 million people throughout the world are chronically infected with HBV. Some of these people will develop hepatic cirrhosis with decompensation and/or hepatocellular carcinoma. For such patients, liver transplantation may be the only hope for cure or real improvement in quality and quantity of life. Formerly, due to rapidity of recurrence of HBV infection after liver transplantation, usually rapidly progressive, liver transplantation was considered to be contraindicated. This changed dramatically following the demonstration that hepatitis B immune globulin (HBIG), could prevent recurrent HBV infection. HBIG has been the standard of care for the past two decades or so. Recently, with the advent of highly active inhibitors of the ribose nucleic acid polymerase of HBV (entecavir, tenofovir), there has been growing evidence that HBIG needs to be given for shorter lengths of time; indeed, it may no longer be necessary at all. In this review, we describe genetic variants of HBV and past, present, and future prophylaxis of HBV infection during and after liver transplantation. We have reviewed the extant medical literature on the subject of infection with the HBV, placing particular emphasis upon the prevention and treatment of recurrent HBV during and after liver transplantation. For the review, we searched PubMed for all papers on the subject of "hepatitis B virus AND liver transplantation". We describe some of the more clinically relevant and important genetic variations in the HBV. We also describe current practices at our medical centers, provide a summary and analysis of comparative costs for alternative strategies for prevention of recurrent HBV, and pose important still unanswered questions that are in need of answers during the next decade or two. We conclude that it is now rational and cost-effective to decrease and, perhaps, cease altogether, the routine use of HBIG during and following liver transplantation for HBV infection. Here we propose an individualized prophylaxis regimen, based on an integrated approach and risk-assessment.
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Kasraianfard A, Watt KD, Lindberg L, Alexopoulos S, Rezaei N. HBIG Remains Significant in the Era of New Potent Nucleoside Analogues for Prophylaxis Against Hepatitis B Recurrence After Liver Transplantation. Int Rev Immunol 2014; 35:312-324. [DOI: 10.3109/08830185.2014.921160] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Campsen J, Zimmerman M, Trotter J, Hong J, Freise C, Brown RS, Cameron A, Ghobrial M, Kam I, Busuttil R, Saab S, Holt C, Emond JC, Stiles JB, Lukose T, Chang MS, Klintmalm G. Multicenter review of liver transplant for hepatitis B-related liver disease: disparities in gender and ethnicity. Clin Transplant 2013; 27:829-37. [PMID: 24033475 DOI: 10.1111/ctr.12224] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2013] [Indexed: 12/15/2022]
Abstract
Orthotopic liver transplantation (OLT) is the preferred treatment for selected patients with hepatitis B virus (HBV)-related liver disease. This study aimed to (i) define long-term outcomes following OLT for HBV; (ii) to quantify the incidence of HBV recurrence (rHBV) as it relates to anti-HBV treatment; and (iii) to determine outcomes for specific patient subgroups. We performed a retrospective chart review of 738 patients undergoing OLT between 1985 and 2010 at seven US transplant centers and divided the patients into 3 eras, 1985-1994, 1995-2004, and 2005-2010, based on hepatitis B immunoglobulin and antiviral therapies. In Era 3, female gender (p = 0.002), recurrent hepatocellular cancer (p < 0.001), and retransplantation (p = 0.01) were significantly associated with worse survival on multivariate analysis. Survival at three yr was poor for all ethnicities in Era 1, but significantly improved for all except black Americans by Era 3. Era 2 data showed a continued increase in rHBV from five to 10 yr (16.6%, 26.2%). In conclusion, while OLT outcomes have improved because of combination antiviral and immunoglobulin therapy, women and black Americans may not have realized an equal benefit. The rate of rHBV is significant even 10 yr post-transplant with survival affected.
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Affiliation(s)
- Jeffrey Campsen
- Baylor University Medical Center at Dallas, Dallas, TX, USA; University of Utah Health Sciences Center, Salt Lake City, UT, USA
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9
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Campsen J, Zimmerman M, Trotter J, Hong J, Freise C, Brown R, Cameron A, Ghobrial M, Kam I, Busuttil R, Saab S, Holt C, Emond J, Stiles J, Lukose T, Chang M, Klintmalm G. Liver transplantation for hepatitis B liver disease and concomitant hepatocellular carcinoma in the United States With hepatitis B immunoglobulin and nucleoside/nucleotide analogues. Liver Transpl 2013; 19:1020-9. [PMID: 23852663 DOI: 10.1002/lt.23703] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 06/03/2013] [Indexed: 12/24/2022]
Abstract
Reinfection with hepatitis B virus (HBV) after liver transplantation (LT) may favor the recurrence of hepatocellular carcinoma (HCC), and combination therapy with hepatitis B immunoglobulin (HBIG) and nucleoside/nucleotide analogues may reduce HBV recurrence after LT. To test associations between HBV, HCC, and survival, we performed a retrospective chart review of patients undergoing LT for HBV between January 1985 and December 2010 at 7 US transplant centers. After we divided the patients into 3 eras based on evolving strategies in antiviral therapy (1985-1994, 1995-2004, and 2005-2010), we reviewed 16 variables to determine whether there were associations between survival and HCC recurrence. Seven hundred thirty-eight patients underwent transplantation for HBV, and 354 (48.0%) had concomitant HCC, which recurred in 58 patients (16.4%). Three-year survival was much better in era 3 versus era 1 (87% versus 40%, P = 0.001), and the incidence of HCC recurrence was lower (12% versus 29%, P = 0.009). The lungs were the most frequent first site of HCC recurrence, and they were followed by the liver. A multivariate analysis showed that HBV reinfection, HCC recurrence, and HBIG use were associated with worse survival (P < 0.001, P < 0.001, and P = 0.002, respectively); HCC recurrence and stage 3 HCC, among other factors, were associated with HBV reinfection (P < 0.001 and P = 0.004); and stage 3 HCC, vascular invasion of the explanted tumor, and post-LT chemotherapy were associated with HCC recurrence (P = 0.008, P < 0.001, and P < 0.001, respectively). Patients with HBV reinfection were 3.6 times more likely than patients without HBV to have HCC recurrence. These data suggest further study of attempts at LT for patients with HBV and HCC beyond the Milan criteria if their HBV is aggressively and successfully treated.
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Affiliation(s)
- Jeffrey Campsen
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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Teperman LW, Poordad F, Bzowej N, Martin P, Pungpapong S, Schiano T, Flaherty J, Dinh P, Rossi S, Subramanian GM, Spivey J. Randomized trial of emtricitabine/tenofovir disoproxil fumarate after hepatitis B immunoglobulin withdrawal after liver transplantation. Liver Transpl 2013; 19:594-601. [PMID: 23447407 DOI: 10.1002/lt.23628] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 02/13/2013] [Indexed: 12/13/2022]
Abstract
Long-term prophylaxis with hepatitis B immunoglobulin (HBIG) for the prevention of hepatitis B virus (HBV) recurrence after orthotopic liver transplantation (OLT) in patients with chronic HBV infection is inconvenient and costly. This randomized, prospective phase 2 study compared emtricitabine (FTC)/tenofovir disoproxil fumarate (TDF) after HBIG withdrawal to FTC/TDF plus HBIG for the prevention of HBV recurrence after OLT. Forty patients with a median time since liver transplantation of 3.4 years (interquartile range = 1.9-5.6 years) received 24 weeks of open-label FTC/TDF plus HBIG before randomization. Patients who maintained confirmed viral suppression were randomized to continue FTC/TDF plus HBIG (n = 19) or receive FTC/TDF alone (n = 18) for an additional 72 weeks. No patient experienced HBV recurrence through 72 weeks of the study while he or she was receiving the randomized treatment. Both treatment arms were safe and well tolerated; no serious or severe drug-related adverse events were observed. Renal function was consistent with that observed in a posttransplant population. The withdrawal of HBIG after 6 months' treatment with FTC/TDF should be considered in liver transplant recipients to prevent chronic HBV recurrence.
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Affiliation(s)
- Lewis W Teperman
- Mary Lea Johnson Richards Organ Transplant Center, New York University Langone Medical Center, New York, NY 10016, USA.
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Abstract
Hepatitis B virus (HBV), a small and economically packaged double-stranded DNA virus, represents an enormous global health care burden. In spite of an effective vaccine, HBV is endemic in many countries. Chronic hepatitis B (CHB) results in the development of significant clinical outcomes such as liver disease and hepatocellular carcinoma (HCC), which are associated with high mortality rates. HBV is a non-cytopathic virus, with the host's immune response responsible for the associated liver damage. Indeed, HBV appears to be a master of manipulating and modulating the immune response to achieve persistent and chronic infection. The HBV precore protein or hepatitis B e antigen (HBeAg) is a key viral protein involved in these processes, for instance though the down-regulation of the innate immune response. The development of new therapies that target viral proteins, such as HBeAg, which regulates of the immune system, may offer a new wave of potential therapeutics to circumvent progression to CHB and liver disease.
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Affiliation(s)
- Renae Walsh
- Research and Molecular Development, Victorian Infectious Diseases Reference Laboratory, North Melbourne, Victoria 3051, Australia.
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12
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Fox AN, Terrault NA. The option of HBIG-free prophylaxis against recurrent HBV. J Hepatol 2012; 56:1189-1197. [PMID: 22274310 DOI: 10.1016/j.jhep.2011.08.026] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 08/01/2011] [Accepted: 08/10/2011] [Indexed: 12/17/2022]
Abstract
Since the early 1990's, hepatitis B immune globulin (HBIG) has been central to the prevention of hepatitis B virus (HBV) recurrence after liver transplantation. When used in combination with oral nucleos(t)ide analogues, HBIG prevents reinfection with HBV in ⩾90% of transplant recipients. While HBIG is highly efficacious, its use is undermined by its high cost. Because of this limitation, there have been many studies of alternative regimens seeking to minimize the dose or duration of HBIG without sacrificing low HBV recurrence rates. Toward that goal, lower dose intramuscular HBIG in combination with oral nucleos(t)ide analogues has been shown to be highly efficacious in preventing disease recurrence and represents a significant cost savings when compared with high dose intravenous administration. The withdrawal of HBIG after a defined course of combination HBIG and oral antivirals has also been shown to be effective, particularly if combination antiviral therapy is used. The ability to achieve undetectable HBV DNA levels pre-transplantation in the majority of patients may contribute to the high efficacy of these HBIG "light" regimens. Additionally, the success of antiviral rescue therapy for those patients who fail prophylaxis and develop recurrent HBV infection post-transplant has provided the impetus to move increasingly towards HBIG-free approaches. New techniques to detect occult HBV in hepatic and extrahepatic sites may allow clinicians to define a subgroup of patients in whom withdrawal of HBIG or all prophylaxis may be applicable.
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Affiliation(s)
- Alyson N Fox
- Medicine and Transplant Surgery, University of California San Francisco, San Francisco, United States
| | - Norah A Terrault
- Medicine and Transplant Surgery, University of California San Francisco, San Francisco, United States.
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13
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Wang K, Zhu ZJ, Zheng H, Deng YL, Pan C, Sun LY, Shen ZY. Protective hepatitis B surface antibodies in blood and ascites fluid in the early stage after liver transplantation for hepatitis B diseases. Hepatol Res 2012; 42:280-7. [PMID: 22176205 DOI: 10.1111/j.1872-034x.2011.00926.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study is to identify the titres of protective hepatitis B surface antibodies (anti-HBs) in the blood and their effective factors in the early stage after liver transplantation (LT) for hepatitis B virus (HBV) related diseases. The condition of anti-HBs lost in ascites fluid was also investigated. METHODS Twenty-six patients who received LT were administered prophylaxis of lamivudine combining intravenous hepatitis B immunoglobulin (HBIG) post-LT. The titres of anti-HBs were recorded and analyzed daily in blood and ascites fluid within the first week post-LT. RESULTS In the first 5 days post-LT, the titres of anti-HBs in HBV DNA positive groups, high hepatitis B surface antigen (HBsAg) groups, hepatitis B e antigen (HBeAg) positive groups were lower than that in the parallel HBV DNA negative groups, low HBsAg groups and HBeAg negative groups. The mean titre level of anti-HBs in ascites fluid is 224.89 IU/L and fluctuated from 0.00 IU/L to 968.50 IU/L, which is also correlated with anti-HBs titres in blood drawn at the same time (r = 0.927, P = 0.000). The level of anit-HBs in ascites fluid was very high; however, it fluctuated in a wide range (from 0.00 IU to 908.55 IU). CONCLUSIONS Patients in high risk groups should receive a higher level of HBIG to maintain sufficient amounts of anti-HBs in the early stage post-LT, while the patients in low risk groups need a lower level of HBIG administration. Furthermore, the lost amount of anti-HBs in ascitic fluid post-LT has minimum impact on the anti-HBs titres in blood.
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Affiliation(s)
- Kai Wang
- Department of Transplant Surgery, First Center Hospital Clinic Institute, Tianjin Medical University, Tianjin, China
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14
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Dindoost P, Jazayeri SM, Alavian SM. Hepatitis B immune globulin in liver transplantation prophylaxis: an update. HEPATITIS MONTHLY 2012; 12:168-76. [PMID: 22550524 PMCID: PMC3339416 DOI: 10.5812/hepatmon.832] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 12/26/2011] [Accepted: 01/29/2012] [Indexed: 12/11/2022]
Abstract
CONTEXT Liver transplantation is the best treatment option for end-stage liver disease following hepatitis B (HBV) infection. However, the high rate of recurrence of HBV infection following transplantation is a disadvantage of this option. EVIDENCE ACQUISITION Over the past 2 decades, the gold standard of prophylactic treatment for the prevention of HBV re-infection following liver transplantation has been the administration of low- to high-dose hepatitis B immune globulin (HBIg) along with an antiviral agent to induce passive immunity. RESULTS The effectiveness of HBIg in preventing the recurrence of HBV depends on the dosage, route of administration, and duration of HBIg treatment, and the viremic status at the time of transplantation. There is currently no consensus on a standardized recommendation for therapeutic options that include HBIg administration. CONCLUSION This review attempts to summarize the available data on the feasibility of such options. Most recent studies support the use of long-term combination therapy of HBIg and antiviral NAs (especially new agents).
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Affiliation(s)
| | - Seyed Mohammad Jazayeri
- Hepatitis B Molecular Laboratory, Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Seyed Moayed Alavian
- Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Seyed Moayed Alavian, Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, IR Iran. Tel.: +98-2188945186, Fax: +98-2181262072, E-mail:
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15
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Hepatitis B Immune Globulin in Liver Transplantation Prophylaxis: An Update. HEPATITIS MONTHLY 2012. [DOI: 10.5812/hepatmon.5124] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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Abstract
The management of hepatitis B in liver transplantation has evolved significantly over the past 2 decades. Introduction of hepatitis B immune globulin and subsequently nucleos(t)ide analogues has revolutionized transplantation for hepatitis B virus (HBV), increasing survival for patients transplanted for this indication. With the availability of new and potent antivirals for HBV, the need for liver transplant should continue to decrease in the coming years. Moreover, the newer antivirals with high resistance barriers will allow effective long-term viral prophylaxis and therefore, prevention of recurrence.
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Affiliation(s)
- Corinne Buchanan
- Center for Liver Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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The role of HBIg as hepatitis B reinfection prophylaxis following liver transplantation. Langenbecks Arch Surg 2011; 397:697-710. [DOI: 10.1007/s00423-011-0795-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 03/28/2011] [Indexed: 12/23/2022]
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Does pre-liver transplant HBV DNA level affect HBV recurrence or survival in liver transplant recipients receiving HBIg and nucleos(t)ide analogues? Ann Hepatol 2011. [DOI: 10.1016/s1665-2681(19)31567-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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19
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Current use of hepatitis B immune globulin for prevention of de novo hepatitis B in recipients receiving anti-HBc-positive livers. Hepatol Int 2011; 5:635-43. [PMID: 21484133 DOI: 10.1007/s12072-010-9250-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 12/31/2010] [Indexed: 01/10/2023]
Abstract
Livers from donors positive for antibody against anti-HBc can potentially transmit de novo hepatitis B (DNH) to their recipients. Despite a good outcome, prophylaxis is usually offered to such recipients. There is no consensus on the standard prophylactic regimen and hence prophylaxis varies among different transplant centres. Nonetheless, hepatitis B immune globulin (HBIG) is considered the mainstay of such prophylaxis, either alone or in combination with an oral antiviral treatment. We aim to provide a concise review of the current use of HBIG in prevention of DNH. We also address a few important questions regarding HBIG use.
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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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Efficacy, safety, and pharmacokinetics of intramuscular hepatitis B immune globulin, Igantibe, for the prophylaxis of viral B hepatitis after liver transplantation. Dig Liver Dis 2010; 42:509-14. [PMID: 19828386 DOI: 10.1016/j.dld.2009.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Revised: 08/12/2009] [Accepted: 09/11/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Long-term prophylaxis of hepatitis B virus (HBV) positive liver transplanted subjects with intravenous hepatitis B immunoglobulin (HBIG) is effective, however use of intramuscular HBIG could be as effective with fewer adverse events and lower cost. AIM We conducted a prospective, non-randomized, clinical study to assess the efficacy and safety of HBIG from Grifols, Igantibe, for the prophylaxis of HBV reactivation. METHODS Eighteen adult patients submitted to liver transplantation for HBV-related disease more than 18 months earlier were treated with doses of 2000 I.U. intramuscular Igantibe every 14 days for 6 months. RESULTS Mean trough serum HBsAb IgG titers from months 4 to 6 (primary efficacy variable) were protective (>or=150 I.U./L) at each time point. Individual measurements were also protective throughout the study. HBV replication remained negative for all available subjects until study completion. Pharmacokinetic analysis showed a half-life of 27 days and extensive exposure to the study drug. Safety and tolerability of intramuscular Igantibe were good, with only one adverse event. CONCLUSION Standard-dose intramuscular Igantibe administration proved efficacious in post-liver transplantation prophylaxis by attaining protective levels for up to 6 months, was safe and well tolerated. Pharmacokinetic analysis revealed a long half-life and extensive exposure.
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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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23
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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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Beckebaum S, Sotiropoulos GC, Gerken G, Cicinnati VR. Hepatitis B and liver transplantation: 2008 update. Rev Med Virol 2009; 19:7-29. [DOI: 10.1002/rmv.595] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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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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26
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Hoch JS, Dewa CS. A clinician's guide to correct cost-effectiveness analysis: think incremental not average. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2008; 53:267-74. [PMID: 18478830 DOI: 10.1177/070674370805300408] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To explain how to correctly report the results from a cost-effectiveness analysis (CEA). METHODS Results were used from a hypothetical clinical trial to illustrate how different ways of reporting economic results affect both presentation of findings and formulation of conclusions. To provide context, we reviewed some high-profile exchanges in the scientific literature. RESULTS The critical issue with which decision makers must grapple involves the trade-offs introduced by a new treatment or intervention. Specifically, are decision makers willing to pay the additional cost for the additional outcomes? This question cannot be considered without estimates of the additional cost and additional outcomes. Correct cost-effectiveness measures, such as the incremental cost-effectiveness ratio or the incremental net benefit, address this issue. CONCLUSIONS As decision makers face the challenge of balancing increasing health care demand with cost containment, it will be crucial to identify cost-effective ways of providing care. Health care providers and other decision makers should not be misled by the results of improperly reported CEAs. Decisions around adoption of pharmaceuticals or implementation of new programs or interventions may be affected by which cost-effectiveness summary measure is reported. Thus consumers of CEA must have a basic understanding of why different methods give different results, and how the results should be interpreted.
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Affiliation(s)
- Jeffrey S Hoch
- Department of Health Policy, Management and Evaluation, Centre for Research on Inner City Health, The Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Ontario.
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Yilmaz N, Shiffman ML, Todd Stravitz R, Sterling RK, Luketic VA, Sanyal AJ, Maluf D, Coterell A, Posner MP, Fisher RA. Prophylaxsis against recurrance of hepatitis B virus after liver transplantation: a retrospective analysis spanning 20 years. Liver Int 2008; 28:72-8. [PMID: 17983429 DOI: 10.1111/j.1478-3231.2007.01611.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Liver transplantation (LT) in patients with hepatitis B virus (HBV) infection is associated with a high rate of graft loss and poor survival, unless re-infection can be prevented. Human hepatitis B immune globulin (HBIG) has long been utilized to prevent re-infection. More recently, an anti-viral agent has been utilized along with HBIG. However, the regimens utilized have varied considerably among LT programmes and the optimal regimen has never been defined. We conducted a retrospective analysis of 41 patients who underwent LT for HBV at our centre since 1985 and received either HBIG with or without an anti-viral agent. The mean age of these patients was 46 years; 81% were male and 88% white. The mean and maximal follow-up were 5.9 and 15 years respectively. Eight out of 15 E-antigen-positive patients who received HBIG alone developed recurrence after a mean of 17 months. In contrast, none of 10 E-Ag-negative patients who received HBIG alone and none of the 10 E-antigen-positive patients who received both HBIG and either lamivudine or adefovir developed recurrence. As long as the anti-HB surface remained detectable, no absolute minimum serum level appeared to lead to recurrent HBV. We concluded that recurrence of HBV following LT can be prevented in E-antigen-positive patients with a combination of HBIG and an anti-viral agent. In contrast, recurrence can be prevented in E-antigen-negative patients with HBIG alone. Maintaining a serum anti-HB surface level above a minimum arbitrary titre of 200 pg/mL did not appear to be necessary for effective HBIG prophylaxis.
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Affiliation(s)
- Nevin Yilmaz
- Hepatology Section, Virginia Commonwealth University Medical Center, Richmond, VA 23298, USA
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Buti M, Mas A, Prieto M, Casafont F, González A, Miras M, Herrero JI, Jardi R, Esteban R. Adherence to Lamivudine after an early withdrawal of hepatitis B immune globulin plays an important role in the long-term prevention of hepatitis B virus recurrence. Transplantation 2007; 84:650-4. [PMID: 17876280 DOI: 10.1097/01.tp.0000277289.23677.0a] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Lamivudine combined with hepatitis B immune globulin (HBIg) is the standard of care for preventing the recurrence hepatitis B virus after liver transplant. To determine the risk of hepatitis B virus (HBV) recurrence after early withdrawal of HBIg in patients receiving lamivudine maintenance therapy, 20 patients receiving a course of HBIg and lamivudine after transplantation and long-term maintenance therapy with lamivudine and 9 patients receiving HBIg and lamivudine indefinitely were analyzed. The survival rate was 90% after a mean follow-up of 83 months. The HBV recurrence rate was 14% with a mean period of 91 months free from HBV recurrence. Both groups had similar HBV recurrence rates, 15% for the combination and 11% for lamivudine alone. Four patients, 3 of whom were noncompliant with therapy, experienced posttransplant HBV recurrence. Patients who adhere to long-term prophylaxis with lamivudine after early withdrawal of HBIg have a low risk of HBV recurrence, similar to those who receive combination prophylaxis.
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Affiliation(s)
- Maria Buti
- Hospital General Valle de Hebrón and CIBER EHD, Barcelona, Spain. mbuti@vhebronnet
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Prophylaxis of hepatitis B recurrence in post-liver transplantation patients with lamivudine-resistant YMDD mutant. Chin Med J (Engl) 2007. [DOI: 10.1097/00029330-200708020-00004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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30
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Jiao ZY, Jiao Z. Prophylaxis of Recurrent Hepatitis B in Chinese Patients After Liver Transplantation Using Lamivudine Combined With Hepatitis B Immune Globulin According to the Titer of Antibody to Hepatitis B Surface Antigen. Transplant Proc 2007; 39:1533-6. [PMID: 17580182 DOI: 10.1016/j.transproceed.2007.03.062] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2006] [Accepted: 03/19/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND/AIMS We sought to determine the outcomes of long-term use of lamivudine combined with hepatitis B immune globulin according to the titer of antibody to hepatitis B surface antigen in preventing recurrent hepatitis B in Chinese patients after liver transplantation. METHODS Eighty-five patients with detectable hepatitis B envelope antigen in serum before liver transplantation were retrospectively enrolled in the study. Twenty-eight patients used lamivudine monotherapy as a control group. Fifty-seven patients used lamivudine combined with hepatitis B immune globulin therapy according to the titer of antibody to hepatitis B surface antigen. RESULTS In the lamivudine monotherapy group, seven patients had recurrent hepatitis B after transplantation, with 1-, 2-, and 3-year recurrence rates of 10.70%, 21.90%, and 25.8%, respectively. In the combination therapy group, three patients had recurrent hepatitis B after transplantation, with 1-, 2-, and 3-year recurrence rates of 0.00%, 5.50%, and 13.40% (P = .03). YMDD mutants were detected in 6 of the 10 patients with recurrent hepatitis B. HBV-DNA load before transplantation was significantly associated with recurrent hepatitis B after transplantation in the overall patients (P = .04). CONCLUSIONS Long-term use of lamivudine combined with hepatitis B immune globulin, according to the titer of antibody to hepatitis B surface antigen was efficacious and cost effective to prevent recurrent hepatitis B in Chinese patients after liver transplantation.
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Affiliation(s)
- Z-Y Jiao
- West China Liver Transplantation Center, Guoxuexiang no. 37, Chengdu, Sichuan 610041, China
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Eisenbach C, Sauer P, Mehrabi A, Stremmel W, Encke J. Prevention of hepatitis B virus recurrence after liver transplantation. Clin Transplant 2007; 20 Suppl 17:111-6. [PMID: 17100710 DOI: 10.1111/j.1399-0012.2006.00609.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Liver transplantation for hepatitis B virus (HBV)-related liver disease has changed from a contraindication to outcomes comparable with non-HBV-related liver transplantations during the last two decades. Mainly the implementation of immunoprophylaxis with hepatitis B immunoglobulin (HBIG) and the use of nucleoside analogs such as lamivudine and adefovir account for this dramatic change. The standard of care in most centers today consists of lamivudine treatment in replicating hepatitis B pre-orthotopic liver transplantation (OLT) and a combination regimen of lamivudine and HBIG post-OLT. With adefovir, a potent antiviral drug became available in recent years that allows for the treatment of patients with lamivudine-resistant tyrosine-methionine-aspartate-aspartate (YMDD)-mutant HBV. In the transplantation setting, first studies indicate that a triple prophylactic therapy consisting of lamivudine, adefovir, and HBIG will become the standard of care for YMDD-mutant-related hepatitis B. With new drugs emerging for the treatment of chronic HBV, there is optimism for new options also in the transplant setting.
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Affiliation(s)
- Christoph Eisenbach
- Department of Internal Medicine IV, University of Heidelberg, Heidelberg, Germany.
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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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Wong SN, Chu CJ, Wai CT, Howell T, Moore C, Fontana RJ, Lok ASF. Low risk of hepatitis B virus recurrence after withdrawal of long-term hepatitis B immunoglobulin in patients receiving maintenance nucleos(t)ide analogue therapy. Liver Transpl 2007; 13:374-81. [PMID: 17318855 DOI: 10.1002/lt.21041] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatitis B virus (HBV) recurrence rates of 0-16% had been reported in patients maintained on nucleoside analogues (NA) after hepatitis B immunoglobulin (HBIG) discontinuation after orthotopic liver transplantation (OLT). However, follow-up in most studies was short. We aimed to determine the long-term risk of HBV recurrence using this strategy. All HBV patients who received > or =7 doses of intravenous HBIG after OLT, with no HBV recurrence while receiving HBIG, and who eventually discontinued HBIG and were maintained on NA, were included. HBV recurrence was defined as HBsAg-positive or HBV DNA > or =5 log copies/mL on 2 consecutive occasions. Twenty-one patients met the inclusion criteria. Immediate post-OLT prophylaxis was combination HBIG and NA in 15 patients, whereas 6 patients received HBIG monotherapy for 62-109 months before NA was added. HBIG was discontinued a median of 26 (range, 0.2-121) months after OLT. Median follow-up post-HBIG discontinuation was 40 (range, 5-51) months. Only 1 patient, who had 12 months of HBIG and was noncompliant to NA therapy, had HBV recurrence, 34 months after HBIG discontinuation. One patient had HBV DNA of 3.3 log copies/mL 47 and 48 months after HBIG discontinuation but remained HBsAg-negative. Lamivudine-resistant mutations were detected in both patients. Probability of HBV recurrence was 0% and 9% at 2 and 4 years after HBIG discontinuation. Three patients had 1-2 episodes of transiently detectable HBV DNA. All were HBV DNA and HBsAg negative on repeated tests over a period of 2-36 months. Maintenance therapy with NA after discontinuation of long-term HBIG therapy is associated with a low risk of HBV recurrence after OLT in compliant HBV patients.
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Affiliation(s)
- Stephen N Wong
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI 48109-0362, USA
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Lo CM, Lau GK, Chan SC, Fan ST, Wong J. Efficacy of a pre-S containing vaccine in patients receiving lamivudine prophylaxis after liver transplantation for chronic hepatitis B. Am J Transplant 2007; 7:434-9. [PMID: 17283489 DOI: 10.1111/j.1600-6143.2006.01636.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Lamivudine monoprophylaxis against hepatitis B virus (HBV) reinfection after liver transplantation is associated with recurrence due to escape mutants and second generation recombinant HBV vaccine is not effective. We studied the efficacy of two courses each of three double-doses (20 microg) of third-generation recombinant pre-S containing vaccine (Sci-B-Vac) in 20 patients on lamivudine prophylaxis at a median of 637 days (range, 390-2666 days) after transplantation. At enrollment, all patients were seronegative for HBsAg, anti-HBs and HBVDNA (by qPCR). Lamivudine (100 mg/day) was continued throughout the study. Five patients (25%) responded to the first course and five additional patients responded after the second course (overall response rate 50%). The response rate was 88% in patients younger than 50 years old and 25% in older patients (p = 0.02). The median peak anti-HBs titer was 153 mIU/mL with six responders having a titer >100 mIU/mL and seven sustained >6 months. Among seven previous nonresponders to second generation recombinant vaccine, three (44%) responded. At the end of the study, all patients remained seronegative for HBsAg. In conclusion, Sci-B-Vac is effective in about 50% of patients receiving lamividine prophylaxis and may prevent recurrence due to escape mutants.
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Affiliation(s)
- C-M Lo
- Centre for the Study of Liver Disease, The University of Hong Kong, Pokfulam, Hong Kong, China.
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35
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Prevention and treatment of hepatitis B virus recurrence after liver transplantation. Curr Opin Organ Transplant 2006. [DOI: 10.1097/mot.0b013e3280102b22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nath DS, Kalis A, Nelson S, Payne WD, Lake JR, Humar A. Hepatitis B prophylaxis post-liver transplant without maintenance hepatitis B immunoglobulin therapy. Clin Transplant 2006; 20:206-10. [PMID: 16640528 DOI: 10.1111/j.1399-0012.2005.00467.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND We examined outcomes in recipients who underwent a liver transplant for HBV-induced liver disease and received a protocol for prophylaxis that did not use HBIG maintenance. RESULTS Between October 2002 and July 2005, a total of 14 liver transplant recipients were identified that met the study criteria. Mean recipient age was 47.6 yr; mean donor age was 37.2 yr. Category of transplant was as follows: cadaveric liver (n = 10, 71%), cadaveric split-liver (n = 2, 14%), and cadaveric liver-kidney (n = 2, 14%). Liver disease was diagnosed at a mean of 7.3 yr before transplant; three (21%) had a coexisting hepatocellular cancer at the time of transplant. Pre-transplant, all 14 (100%) recipients were hepatitis B surface antigen (HBsAg) positive, and 11 (79%) were HBV DNA positive (mean viral load of 251.2 pg/mL). Three (21%) were E antigen positive, and one (7%) was D antigen positive. Pre-transplant, seven patients (50%) were on anti-viral therapy and there was documented diminution in viral loads after initiating anti-viral therapy in 3 cases. Three (21%) were hepatitis C virus (HCV) antigen positive and all had low-RNA titers. With mean follow-up of 14.1 months, all 14 patients are alive with a functioning graft. Mean ALT, AST and total bilirubin values are currently at 43.2, 32.2, and 0.84, respectively. One recipient remains HBsAg surface antigen positive post-transplant but has normal lab values. The remaining recipients have no evidence of HBV recurrence by serology and protocol biopsies. The regimen has been well tolerated without the need for drug reduction or discontinuation because of side-effects. CONCLUSION Longer follow-up is needed, but this regimen may represent an alternative to chronic HBIG maintenance therapy.
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Affiliation(s)
- Dilip S Nath
- Department of Surgery, University of Minnesota Medical School, Minneapolis, 55455, USA
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Samuel D, Forns X, Berenguer M, Trautwein C, Burroughs A, Rizzetto M, Trepo C. Report of the monothematic EASL conference on liver transplantation for viral hepatitis (Paris, France, January 12-14, 2006). J Hepatol 2006; 45:127-43. [PMID: 16723165 DOI: 10.1016/j.jhep.2006.05.001] [Citation(s) in RCA: 140] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Didier Samuel
- HepatoBiliary Centre, Inserm-Paris XI U 785, Paul Brousse Hospital, APHP, Villejuif, France.
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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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Thürmann PA, Szymanski J, Haffner S, Tenter U, Grieger F, Sonnenburg C. Pharmacokinetics and safety of a novel anti-HBs-enriched immunoglobulin in healthy volunteers after subcutaneous and intramuscular administration. Eur J Clin Pharmacol 2006; 62:511-2. [PMID: 16676173 DOI: 10.1007/s00228-006-0137-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2006] [Accepted: 03/27/2006] [Indexed: 11/28/2022]
Affiliation(s)
- Petra A Thürmann
- Philipp Klee-Institute of Clinical Pharmacology, HELIOS Klinikum Wuppertal, University Witten/Herdecke, Heusnerstr. 40, 42283, Wuppertal, Germany.
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40
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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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41
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Targhetta S, Villamil F, Inturri P, Pontisso P, Fagiuoli S, Cillo U, Cecchetto A, Gianni S, Naccarato R, Burra P. Protocol liver biopsies in long-term management of patients transplanted for hepatitis B-related liver disease. World J Gastroenterol 2006; 12:1706-12. [PMID: 16586538 PMCID: PMC4124344 DOI: 10.3748/wjg.v12.i11.1706] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the long-term histological outcome of patients transplanted for HBV-related liver disease and given HBIg prophylaxis indefinitely after LT.
METHODS: Forty-two consecutive patients transplanted for hepatitis B were prospectively studied. HBsAg, HBV-DNA and liver function tests were evaluated in the serum 3, 6 and 12 mo after LT and then yearly. LB was obtained 6 and 12 mo after LT and yearly thereafter. Chronic hepatitis (CH) B after LT was classified as minimal, mild, moderate or severe.
RESULTS: HBV recurred in 7/42 (16.6 %) patients after 6-96 mo of follow-up. A hundred and eighty-seven LB were evaluated. Four of 7 patients with graft reinfection, all with unknown HBV DNA status before LT, developed cirrhosis at 12-36 mo of follow-up. Of the 122 LB obtained from 28 HBsAg+/HCV- recipients with no HBV recurrence after LT, all biopsies were completely normal in only 2 patients (7.1 %), minimal/non-specific changes were observed in 18 (64.2 %), and at least 1 biopsy showed CH in the remaining 8 (28.5 %). Twenty-nine LB obtained from 7 patients transplanted for HBV-HCV cirrhosis and remaining HBsAg- after LT revealed recurrent CH-C. Actuarial survival was similar in patients with HBsAg+ or HBsAg- liver diseases.
CONCLUSION: Though protocol biopsies may enable the detection of graft dysfunction at an early stage, the risk of progression and the clinical significance of these findings remains to be determined.
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Affiliation(s)
- Stefano Targhetta
- Department of Surgical and Gastroenterological Sciences, Gastroenterology Section, University Hospital, University of Padua, Via Giustiniani 2, 35128 Padua, Italy
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42
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Roche B, Samuel D. [Liver transplantation for complications of hepatitis B]. Presse Med 2006; 35:335-45. [PMID: 16493338 DOI: 10.1016/s0755-4982(06)74579-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
In the absence of prophylaxis, there is an elevated risk of virus recurrence after liver transplantation required because of chronic hepatitis B. Regardless of prophylaxis, the risk of recurrence is associated with pre-graft viral load. Long-term prophylaxis by hepatitis B immune globulin (HBIG) significantly reduces the risk of recurrence, especially if there was no pre-graft viral replication. Use of antiviral agents such as lamivudine, adefovir, tenofovir, and entecavir, control HBV replication in patients with decompensation of cirrhosis while awaiting transplantation and in patients with HBV recurrence post-graft. The risk of emergence of resistant strains limits the use of these antiviral agents. The choice of one or several combined antiviral agents depends on their resistance profiles. Combining antiviral agents and HBIG after transplantation can reduce the risk of HBV recurrence to less than 10%, even in patients with viral replication pre-graft. If there was no detectable viral load pre-graft, withdrawal of HBIG should be considered at some point, while continuing an antiviral agent or after anti-HBV vaccination.
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Affiliation(s)
- Bruno Roche
- Centre hépatobiliaire, Hôpital Paul Brousse, Villejuif.
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43
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Tung BY, Kowdley KV. Hepatitis B and Liver Transplantation. Clin Infect Dis 2005; 41:1461-6. [PMID: 16231258 DOI: 10.1086/497129] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2005] [Accepted: 06/23/2005] [Indexed: 01/28/2023] Open
Abstract
Liver transplantation is the treatment of choice for patients with liver failure secondary to chronic hepatitis B. However, liver transplantation is complicated by the risk of recurrent hepatitis B virus infection, which significantly impairs graft and patient survival. The main risk factor for the development of recurrent hepatitis B virus infection is the virus load at the time of transplantation. The development of antiviral medications, such as lamivudine and adefovir, and the implementation of effective prophylactic regimens using hepatitis B immune globulin have significantly improved the outcomes of hepatitis B after liver transplantation. However, current approaches continue to be hampered by the extremely high cost of treatment and the emergence of drug-resistant viral mutations. Ongoing studies are necessary to establish the most cost-effective approaches to prevent recurrent hepatitis B virus infection after liver transplantation.
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Affiliation(s)
- Bruce Y Tung
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA 98195, USA
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44
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De Simone P, Carrai P, Baldoni L, Petruccelli S, Coletti L, Morelli L, Filipponi F. Quality assurance, efficiency indicators and cost-utility of the evaluation workup for liver transplantation. Liver Transpl 2005; 11:1080-5. [PMID: 16123969 DOI: 10.1002/lt.20484] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We report the results of a retrospective review of the outpatient pretransplantation workup for United Network for Organ Sharing (UNOS) 3 patients adopted at a liver transplantation (LT) center and illustrate the efficiency indicators used for quality evaluation and cost-analysis. A single-center, pre-LT evaluation workup was performed on an outpatient basis at a cost per patient evaluation of 2,770 Euros (). Objective measures were: the number of patients admitted to and excluded from each phase of the algorithm; the rate of patients admitted to pre-LT evaluation out of the total of referred patients (the referral efficiency rate); the rate of waitlisted patients out of those admitted to pre-LT evaluation (the evaluation efficiency rate); the rate of waitlisted patients out of those referred for LT (the process efficiency rate); and the cost per waitlisted patient, as the ratio of the cost per patient evaluation to the evaluation efficiency rate. From January 1, 1996, to October 1, 2004, 1,837 patients were referred for LT on an outpatient basis. Based on preemptive evaluation of the available clinical data, 412 patients (22.4%) were excluded from pre-LT evaluation and 1,425 (77.6%) were admitted to preliminary consultation. Among these, 603 (42.3%) were excluded from and 822 (57.7%) were admitted to pre-LT evaluation with a referral efficiency rate of 44.7% (822 of 1,837). Out of the patients evaluated for LT, 484 were waitlisted with a cost-utility and evaluation efficiency rate of 58.8% each (484 of 822). Of the 1,837 patients originally addressed for LT 484 were waitlisted, yielding a process efficiency rate of 26.3% (484 of 1,837) and a cost per waitlisted patient of 4,710.8. In conclusion, the 3 indicators allowed monitoring of the efficiency of the pre-LT evaluation algorithm. The current process efficiency rate at our center is low (26.3%), but avoiding early referrals we might increase it to 31.6%, with a 12% net saving on costs per waitlisted patient (from 4,710.8 to 4,165.4).
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Affiliation(s)
- Paolo De Simone
- Liver Transplant Unit, University of Pisa, Cisanello Hospital, Pisa, Italy
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45
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Lo CM, Liu CL, Chan SC, Lau GK, Fan ST. Failure of hepatitis B vaccination in patients receiving lamivudine prophylaxis after liver transplantation for chronic hepatitis B. J Hepatol 2005; 43:283-7. [PMID: 15964658 DOI: 10.1016/j.jhep.2005.03.013] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2005] [Revised: 02/25/2005] [Accepted: 03/23/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND/AIMS Lamivudine prophylaxis against hepatitis B virus (HBV) reinfection after liver transplantation is associated with recurrence due to escape mutants. METHODS Fifty-two patients on lamivudine prophylaxis at a median of 412 days (median, 370-2040 days) after transplantation for chronic HBV-related liver disease received two courses of an accelerated schedule of double-dose recombinant HBV vaccine. Before vaccination, all patients were seronegative for HBsAg, anti-HBs and HBV DNA (by qPCR). Three intramuscular doses of vaccine (40 microg each) were administered monthly and another identical course was repeated after 3 months. Lamivudine (100mg/day) was continued throughout the study. RESULTS After the first course, two patients developed a weak response (anti-HBs titre of 12 mIU/mL) that disappeared rapidly. One early responder developed anti-HBs (27 mIU/mL) again after the second course but the other did not. Two other patients developed response (anti-HBs titre of 17 and 103 mIU/mL, respectively) giving an overall response rate of 7.7%. The antibody level declined rapidly. At the end of the study, one patient who did not respond had developed viral breakthrough which was treated with adefovir dipivoxil therapy. CONCLUSIONS Active immunization with two courses of double-dose recombinant HBV vaccine has limited efficacy in patients receiving lamividine prophylaxis after liver transplantation.
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Affiliation(s)
- Chung Mau Lo
- Centre for the Study of Liver Disease, Department of Surgery, The University of Hong Kong, Pokfulam, Hong Kong, China.
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46
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Benner A, Lyden E, Rogge J, Weaver L, Mukherjee S. Outcomes of liver transplantation for hepatitis B: a single-center study of 35 patients. Transplant Proc 2005; 36:2741-3. [PMID: 15621137 DOI: 10.1016/j.transproceed.2004.09.048] [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: 11/28/2022]
Abstract
BACKGROUND Results of liver transplantation (LT) for hepatitis B (HBV) have improved in the past decade but recently drug resistance has been described, the clinical significance of which is unclear. The aims of this study were to evaluate outcomes of LT for HBV and describe the prevalence of drug resistance. METHODS A retrospective chart analysis and review of the organ transplant database was performed to identify all patients transplanted for HBV between December 1982 and April 2004 who survived more than 3 months. RESULTS Thirty-five patients were transplanted for HBV during this period: 27 men and 8 women. Median age at LT was 48.8 years (range 18.9 to 74.3). Four patients were transplanted for fulminant liver failure and 31 for decompensated cirrhosis. Intramuscular HBIG was administered to 8 patients and intravenous HBIG to 32 patients, data were unavailable for three patients. Lamivudine was prescribed for 18 patients (58%) pre-OLT and for 31 patients (88.6%) post-LT. Drug-resistant HBV developed in two patients (5.71%) receiving lamivudine and HBIG. Adefovir substitution resulted in improvement in liver function tests, in HBV DNA and in histology in both patients. Twenty-five patients are currently alive with and 1-year survival of 95% and a 5-year survival of 75%. Causes of death were respiratory failure (n = 3), metastatic cancer of unknown primary (n = 2), renal failure (n = 2), sepsis (n = 1), cerebrovascular accident (n = 1), and cerebral edema (n = 1). CONCLUSIONS LT for HBV shows survival rates comparable to other liver transplant recipients. Lamivudine resistance was rare in this series but responded to adefovir substitution.
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Affiliation(s)
- A Benner
- Section of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska 68198-3285, USA
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47
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Terrault N, Roche B, Samuel D. Management of the hepatitis B virus in the liver transplantation setting: a European and an American perspective. Liver Transpl 2005; 11:716-732. [PMID: 15973718 DOI: 10.1002/lt.20492] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Norah Terrault
- University of California at San Francisco, San Francisco, CA
| | - Bruno Roche
- Centre Hépatobiliaire, Hôpital Paul Brousse, Villejuif, France
| | - Didier Samuel
- Centre Hépatobiliaire, Hôpital Paul Brousse, Villejuif, France
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48
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Wang ZX, Fu ZR, Ding GS, Zhang JJ, Fu H, Zhang M, Zhang CY. Prevention of hepatitis B virus reinfection after orthotopic liver transplantation. Transplant Proc 2005; 36:2315-7. [PMID: 15561235 DOI: 10.1016/j.transproceed.2004.07.070] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE We discuss the prevention of hepatitis B virus reinfection following orthotopic liver transplantation. METHODS Sixty-eight cases of chronic fulminant hepatitis B, the end stage of liver cirrhosis and liver carcinoma complicated with HBV cirrhosis, were given antiviral drugs pre- and posttransplantation to prevent hepatitis B virus reinfection. Lamivudine was administered to two cases and lamivudine + HBIG to 63 cases. Adefovir + HBIG was administered to three cases. The serum HBV, HBV DNA, liver biopsy immunohistochemistry and clinical examinations were performed. RESULTS One of two cases given lamivudine developed reinfection with serum HBSAg, HbeAb, HBcAb, HBV DNA, and positive and liver biopsy immunohistochemistry showing HBSAg phenotype. Two of the 63 cases given lamivudine + HBIG developed reinfection with serum HBSAg, HBeAb, HBcAb positive and liver biopsy immunohistochemistry showing HBSAg phenotype. The serum HBV DNA was positive in one of the two cases. Three cases given adefovir developed no reinfection with HBV. CONCLUSION Orthotopic liver transplantation is an effective treatment for HBV infection; lamivudine + HBIG or adefovir + HBIG prevent hepatitis B virus reinfection.
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Affiliation(s)
- Z-X Wang
- Liver Transplantation Group of Transplantation Center, Changzheng Hospital, Second Military University, Shanghai, People's Republic of China
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49
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Roche B, Samuel D. [Prevention and treatment of hepatitis B virus infection after liver transplantation]. ACTA ACUST UNITED AC 2005; 29:393-404. [PMID: 15864201 DOI: 10.1016/s0399-8320(05)80787-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Bruno Roche
- Centre Hépatobiliaire, EA 3541, Université Paris-Sud, Villejuif, France
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50
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Roche B, Samuel D. Treatment of hepatitis B and C after liver transplantation. Part 1, hepatitis B. Transpl Int 2005; 17:746-58. [PMID: 15688165 DOI: 10.1007/s00147-004-0797-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2002] [Revised: 11/25/2003] [Accepted: 01/05/2004] [Indexed: 12/19/2022]
Abstract
The outcome of OLT for HBV-related liver disease is dependent on the prevention of allograft re-infection. Over the past decade, major advances have been made in the management of HBV transplant candidates. The advent of long-term hepatitis B immune globulin (HBIG) administration as a prophylaxis against HBV recurrence, and the introduction of new antiviral agents against HBV infection, such as lamivudine (LAM), were a major breakthrough in the management of these patients. Results of OLT for HBV infection are similar to those achieved with other indications. Pre-OLT antiviral treatment such as LAM can suppress HBV replication before OLT and thus decrease the risk of re-infection of the graft. Combination prophylaxis with LAM and HBIG after transplantation highly effectively reduces the rate of HBV re-infection, even in HBV replicative cirrhotic patients. The optimal HBIG protocol in the LAM era is yet to be defined: dosing of HBIG, routes of administration, and possibility of stopping HBIG. Several antiviral drugs have been developed for the management of HBV infection on the graft, so outcome is currently good.
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Affiliation(s)
- Bruno Roche
- Centre Hepatobiliaire, UPRES 3541, EPI 99-41, Universite Paris-Sud, Hôpital Paul Brousse, 14 Ave. P.V. Couturier, 94800 Villejuif, France
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