Hepatitis B immunoglobulin in combination with lamivudine for prevention of hepatitis B virus reactivation in children undergoing bone marrow transplantation

Sustained seroconversion of chronic hepatitis B infection after stem cell transplantation

  We present an 18-yr-old adolescent with acute lymphocytic leukemia, who underwent peripheral blood SCT with serologically and histologically documented chronic hepatitis B infection. Prior and during the transplant process, lamivudine was administered orally and he underwent SCT with a twofold decrease in viral load at the time of transplant from his HLA full matched, HBV natural immune (anti-HBs and anti-HBc positive) donor. Successful engraftment was achieved and three months after SCT, HBV seroconversion was documented accompanied with an ALT flare. Chronic graft-versus-host disease coincided after the transplantation, and he has been on immunosuppressive treatment for 25 months with sustained HBV seroconversion. We assume that adoptive immunity transfer combined with antiviral treatment might also constitute sustained seroconversion in chronic HBV, besides the reported risk of reactivation.

Management of HBV infection during immunosuppressive treatment

The literature on hepatitis B virus (HBV) in immunocompromised patients is heterogeneous and refers mainly to the pre-antivirals era. Currently, a rational approach to the problem of hepatitis B in these patients provides for: a) the evaluation of HBV markers and of liver condition in all subjects starting immunosuppressive therapies (baseline), b) the treatment with antivirals (therapy) of active carriers, c) the pre-emptive use of antivirals (prophylaxis) in inactive carriers, especially if they are undergoing immunosuppressive therapies judged to be at high risk, d) the biochemical and HBsAg monitoring (or universal prophylaxis in case of high risk immunosuppression, as in onco-haematologic patients and bone marrow transplantation) in subjects with markers of previous contact with HBV (HBsAg-negative and antiHBc-positive), in order to prevent reverse seroconversion. Moreover in solid organ transplants it is suggested a strict adherence to the criteria of allocation based on the virological characteristics of both recipients and donors and the universal prophylaxis or therapy with nucleos(t)ides analogs

Hepatitis B reactivation in allogeneic hemopoietic stem cell transplantation setting: a pediatric experience

Reactivation of HBV is a well known complication in patients undergoing HSCT. Lamivudine treatment appears to prevent hepatitis B virus reactivation and to decrease the mortality in at risk HSCT patients. We describe HBV reactivation occurred in three allogeneic HSCT pediatric patients coming from Eastern Europe, one of whom was successfully treated with lamivudine. Our experience confirms that HBV-DNA may persist as intra-hepatic infection or in extra-hepatic sites and that HBV reactivation may appear during immunodepression. Careful and complete screening for HBV markers is mandatory before HSCT, especially in children coming from countries at risk for HBV. Furthermore, a treatment with lamivudine could also represent an efficacious prophylaxis in pediatric patients to avoid HBV reactivation and to decrease the development of severe hepatic disease.

Clinical characteristics and outcome of morbidly obese bariatric patients with concurrent hepatitis B viral infection

BACKGROUND

Bariatric surgery is the only effective and long-lasting treatment of morbidly obese patients. However, the safety and efficacy of bariatric surgery in patients with hepatitis B viral (HBV) infection is not clear. The aim of the present study is to investigate whether HBV infection influences clinic features and outcomes of bariatric surgery.

METHODS

The preoperative seropositivity of HBV surface antigen (HBsAg) using radioimmunoassay was determined in 592 patients (481 female, 111 male: mean age 30.5 +/- 8.1 years; mean body mass index [BMI] 43.1 +/- 6.0) who had undergone bariatric surgery (209 banding and 383 gastric bypass) for their morbid obesity in the past 5 years. All the clinical data were prospectively collected and stored.

RESULTS

The overall seroprevalence of HbsAg was 18.8%. Morbidly obese patients positive for HBV infection were associated with older age and higher diastolic blood pressure, but not with sex, BMI, liver enzyme, blood lipid, and glucose levels. Although minigastric bypass (MGB) had a better weight reduction than gastric banding, there was no difference in weight reduction between patients who were positive and negative for HBV infection. The weight loss curves and resolution of obesity-related comorbidities were similar between the two groups except the postoperative aspartate transaminase (AST) and alanine transaminase (ALT) were significantly higher in patients who were positive for HBV infection. During follow-up, two patients developed fulminating hepatitis after MGB with one mortality.

CONCLUSION

Morbidly obese patients with the existence of HBV infection do not influence the outcome of bariatric surgery, but continuing monitor of the liver function is indicated.

A prophylactic approach for bone marrow transplantation from a hepatitis B surface antigen-positive donor

It has been accepted that bone marrow transplantation (BMT) is the only curative therapeutic option for certain hematologic malignancies. The southeast Asia region is an endemic area of hepatitis B virus (HBV) infection; thus, BMT using a hepatitis B surface antigen (HBsAg)-positive donor is occasionally unavoidable. Organ transplantation using a HBsAg-positive donor can lead to post-transplantation de novo HBV infection and severe HBV-related hepatitis if no effective prophylactic measures are taken prior to and after transplantation. In this report, a four-level approach was designed for a patient with chronic myeloid leukemia, beginning with a booster HBV vaccination before performing BMT with a HBsAg-positive donor. Prior to BMT, the HBV viral load of the donor was reduced to an undetectable level by antiviral therapy. After BMT, hepatitis B immunoglobulin was administered intramuscularly for 1 wk together with a long-term antiviral drug, lamivudine. One year after discontinuation of lamivudine, the patient is still free of HBV infection.