A multi-center evaluation of hepatitis B reactivation with and without antiviral prophylaxis after kidney transplantation

Utilization of Hepatitis B viremic donors (NAT+) leads to improved kidney transplant access for older adult recipients with little to no wait time

BACKGROUND

Though the use of Hepatitis B viremic (HBV) donor kidneys may be a safe alternative to improve access to transplantation, there has not been wide acceptance of this practice. In this study, we determined the safety and effectiveness of HBV NAT (+) donor kidneys in a protocolized manner in an older adult population.

METHODS

Over a 3-year period, 16 decreased donor kidney transplants were performed with HBV NAT+ kidneys. Recipients of HBV NAT+ kidneys were treated with entecavir started pre-operatively and continued for 52 weeks.

RESULTS

HBV NAT+ kidneys were preferentially used in older (68 ± 5 vs. 64 ± 9 years; p = .01) recipients with less dialysis time (93.8% < 5 years vs. 67% <5 years; p = .03). In this cohort, 3/16 had detectable HBV PCR 1-week post-transplant, but all were negative at 9- and 12-months. Calculated estimated glomerular filtration rate (eGFR) was slightly decreased 12-months post-transplant. Post-transplant outcomes in an age-matched cohort showed no difference in rates of delayed graft function, readmission within 30 days, and graft loss or death within 6 months of transplant (p > .05).

CONCLUSION

Transplants with HBV NAT+ donor kidneys in a pre-emptive treatment protocol allow for increased safe access to transplantation in older adult recipients with little or no dialysis time.

Clinical Significance and Remaining Issues of Anti-HBc Antibody and HBV Core-Related Antigen

Currently, hepatitis B virus (HBV) core antibody (anti-HBc antibody) and HBV core-related antigen (HBcrAg) are widely used as serum markers for diagnosis based on the HBV core region. This review focused on anti-HBc antibodies and HBcrAg and aimed to summarize the clinical significance of currently used assay systems and the issues involved. While anti-HBc is very significant for clinical diagnosis, the clinical significance of quantitative assay of anti-HBc antibody has been reevaluated with improvements in diagnostic performance, including its association with clinical stage and prediction of carcinogenesis and reactivation. In addition, concerning the new HBcrAg, a high-sensitivity assay method has recently been established, and its diagnostic significance, including the prediction of reactivation, is being reevaluated. On the other hand, the quantitative level of anti-HBc antibody expressed in different units among assay systems complicates the interpretation of the results. However, it is difficult to standardize assay systems as they vary in advantages, and caution is needed in interpreting the assay results. In conclusion, with the development of highly sensitive HBcrAg and anti-HBc antibody, a rapid and sensitive detection assay system has been developed and used in clinical practice. In the future, it is hoped that a global standard will be created based on the many clinical findings.

Hepatitis B Virus Reactivation in Kidney Transplant Recipients Treated With Belatacept

Introduction

Hepatitis B virus (HBV) reactivation in kidney transplant recipients has been reported in 3% to 9% of anti-HBc antibody (HBcAb)-positive HBs antigen (HBsAg)-negative patients. It has not been studied in patients receiving belatacept, a selective costimulation blocker.

Methods

We performed a retrospective study of all transplant recipients receiving belatacept in 2 kidney transplantation centers in France. Among HBcAb-positive patients, we analyzed HBV reactivation rate, outcomes, and risk factors.

Results

A total of 135 patients treated with belatacept were included: 32 were HBcAb-positive and 2 were HBsAg-positive. Seven patients reactivated HBV (21.9% of HBcAb-positive patients), including 5 HBsAg-negative patients (16.7% of HBcAb-positive HBsAg-negative patients). Reactivation occurred 54.8 (± 70.9) months after transplantation. One patient presented with severe hepatitis and 1 patient developed cirrhosis. There was no significant difference in survival between patients that reactivated HBV and patients that did not: 5-year patient survival of 100% (28.6; 100) and 83.4% (67.6; 100), respectively (P = 0.363); and 5-year graft survival of 100% (28.6; 100) and 79.8% (61.7; 100), respectively (P = 0.335). No factor, including HBsAb positivity and antiviral prophylaxis, was statistically associated with the risk of HBV reactivation.

Conclusion

HBV reactivation rate was high in patients treated with belatacept when compared with previous transplantation studies. HBV reactivation did not impact survival. Further studies are needed to confirm these results. A systematic antiviral prophylaxis for these patients should be considered and evaluated.

Shifting perspectives in liver diseases after kidney transplantation

Liver diseases after kidney transplantation range from mild biochemical abnormalities to severe hepatitis or cirrhosis. The causes are diverse and mainly associated with hepatotropic viruses, drug toxicity and metabolic disorders. Over the past decade, the aetiology of liver disease in kidney recipients has changed significantly. These relates to the use of direct-acting antiviral agents against hepatitis C virus, the increasing availability of vaccination against hepatitis B and a better understanding of drug-induced hepatotoxicity. In addition, the emergence of the severe acute respiratory syndrome coronavirus 2 pandemic has brought new challenges to kidney recipients. This review aims to provide healthcare professionals with a comprehensive understanding of recent advances in the management of liver complications in kidney recipients and to enable them to make informed decisions regarding the risks and impact of liver disease in this population.

Incidence, risk factors, and clinical outcomes of HBV reactivation in non-liver solid organ transplant recipients with resolved HBV infection: A systematic review and meta-analysis

BACKGROUND

Current guidelines do not recommend routine antiviral prophylaxis to prevent hepatitis B virus (HBV) reactivation in non-liver solid organ transplant (SOT) recipients with resolved HBV infection, even in anti-hepatitis B surface antigen (anti-HBs)-negative recipients and those receiving intense immunosuppression. This systematic review and meta-analysis aimed to determine the incidence, risk factors, and clinical outcomes of HBV reactivation in non-liver SOT recipients.

METHODS AND FINDINGS

Three databases (PubMed, Embase, and Cochrane Library) were systematically searched up to December 31, 2022. Clinical studies reporting HBV reactivation in non-liver SOT recipients were included. Case reports, case series, and cohort studies with a sample size of less than 10 patients were excluded. Random-effects analysis was used for all meta-analyses. We included 2,913 non-liver SOT recipients with resolved HBV infection from 16 retrospective cohort studies in the analysis. The overall HBV reactivation rate was 2.5% (76/2,913; 95% confidence interval [95% CI 1.6%, 3.6%]; I2 = 55.0%). Higher rates of reactivation were observed in recipients with negative anti-HBs (34/421; 7.8%; 95% CI [5.2%, 10.9%]; I2 = 36.0%) by pooling 6 studies, experiencing acute rejection (13/266; 5.8%; 95% CI [2.3%, 14.5%]; I2 = 63.2%) by pooling 3 studies, receiving ABO blood type-incompatible transplantation (8/111; 7.0%; 95% CI [2.9%, 12.7%]; I2 = 0%) by pooling 3 studies, receiving rituximab (10/133; 7.3%; 95% CI [3.4%, 12.6%]; I2 = 0%) by pooling 3 studies, and receiving anti-thymocyte immunoglobulin (ATG, 25/504; 4.9%; 95% CI [2.5%, 8.1%]; I2 = 49.0%) by pooling 4 studies. Among recipients with post-transplant HBV reactivation, 11.0% (7/52; 95% CI [4.0%, 20.8%]; I2 = 0.3%) developed HBV-related hepatic failure, and 11.0% (7/52; 95% CI [4.0%, 20.8%]; I2 = 0.3%) had HBV-related death. Negative anti-HBs (crude odds ratio [OR] 5.05; 95% CI [2.83, 9.00]; p < 0.001; I2 = 0%), ABO blood type-incompatible transplantation (crude OR 2.62; 95% CI [1.05, 6.04]; p = 0.040; I2 = 0%), history of acute rejection (crude OR 2.37; 95% CI [1.13, 4.97]; p = 0.022; I2 = 0%), ATG use (crude OR 3.19; 95% CI [1.48, 6.87]; p = 0.003; I2 = 0%), and rituximab use (crude OR 3.16; 95% CI [1.24, 8.06]; p = 0.016; I2 = 0%) increased the risk of reactivation. Adjusted analyses reported similar results. Limitations include moderate heterogeneity in the meta-analyses and that most studies were conducted in kidney transplant recipients.

CONCLUSIONS

Non-liver SOT recipients with resolved HBV infection have a high risk of HBV-related hepatic failure and HBV-related death if HBV reactivation occurs. Potential risk factors for HBV reactivation include rituximab use, anti-thymocyte immunoglobulin use, anti-HBs negative status, acute rejection history, and ABO blood type-incompatible transplantation. Further research on monitoring and routine antiviral prophylaxis of non-liver SOT recipients at higher risk of HBV reactivation is required.