Hepatitis B surface antigen (HBsAg)-positive kidney transplant recipients have increased liver-related mortality. The impact of lamivudine treatment on patient survival, the optimal time to start treatment, and the feasibility of discontinuing treatment have not been determined. This study examined these issues with a novel management protocol. Serum hepatitis B virus (HBV) DNA levels were measured serially in HBsAg-positive kidney transplant recipients, and lamivudine was administered preemptively to patients with increasing HBV DNA levels with or without elevation of aminotransferase levels. Outcomes of patients who underwent transplantation before or after institution of this preemptive management strategy (in January 1996) were compared. H epatitis B virus (HBV) infection is an importantcause of morbidity and mortality after kidney transplantation. [1][2][3][4][5] The number of chronic HBV carriers exceeds 300 million worldwide, and up to 14% of renal allograft recipients in endemic areas are hepatitis B surface antigen (HBsAg) positive. 6,7 Progressive liver disease affects more than 80% of HBsAg-positive renal transplant recipients 8,9 and accounts for 37% to 57% of mortality. 3,4,9 Life-threatening exacerbation of liver disease can develop in previously healthy HBV carriers. An optimal monitoring and treatment regimen for HBsAg-positive renal allograft recipients has not been defined.Lamivudine is a nucleoside analogue with proven efficacy in suppressing HBV DNA levels and ameliorating aminotransferase and histologic abnormalities in nonimmunosuppressed patients with chronic hepatitis B. 10,11 Short-term studies have shown virologic and biochemical efficacy in small series of renal transplant recipients. [12][13][14][15][16] We and others have reported favorable results with lamivudine in the treatment of fibrosing cholestatic hepatitis B, which hitherto has been associated with nearly uniform mortality. 17,18 However, many critical issues remain unresolved. It is not known whether patient survival can be Abbreviations: HBV, hepatitis B virus; HBsAg, hepatitis B surface antigen; ALT, alanine aminotransferase; HBeAg, hepatitis B e antigen.

Some immunosuppressed patients with hepatitis C virus infection do not have detectable levels of antibody to hepatitis C virus on second-generation enzyme immunoassay. Antibodies to the envelope and nonstructural region 5 proteins have not been examined. Four groups of patients with hepatitis C virus infection were studied: (a) 20 immunocompetent patients, (b) 15 hemodialysis patients, (c) 17 kidney transplant recipients and (d) 3 acute leukemia patients who underwent bone marrow transplantation. Serum samples were tested for antibody to hepatitis C virus with a second-generation enzyme immunoassay and multi-antigen enzyme immunoassays and for hepatitis C virus RNA with a nested polymerase chain reaction assay. All the immunocompetent patients reacted to C25, C22 and C33C; 90% reacted to nonstructural region 5 antigen and 80% reacted to C100-3. Only 55% reacted against yeast-derived e1 and e2 antigens, but all reacted against vaccinia virus--expressed N e1 and e2 antigens, indicating that the envelope epitopes are conformational and glycosylated. Sixty-five percent to 90% of dialysis and kidney transplant patients reacted to C25, C22 and N e1 and e2, but only 12% to 60% reacted to C100-3, C33C and nonstructural region 5 antigen. Diminution or loss of reactivity to hepatitis C virus antigens was observed after kidney and bone marrow transplantation, with C25 and N e1 and e2 less affected. Our data suggest that incorporation of C25 and N e1 and e2 antigens in the assay for antibody to hepatitis C virus would improve the detection of hepatitis C virus infection in immunosuppressed patients.

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Our objectives were to study long-term patient survival and dialysis adequacy of continuous ambulatory peritoneal dialysis (CAPD) patients treated with a standard regime of three 2-L daily exchanges. It was a retrospective analysis of patient survival and cross-sectional analysis of adequacy of dialysis. The setting was a dialysis unit in a tertiary referral center of a teaching hospital. All patients (n = 507) accepted into the CAPD program from 1983 to June 1994, were analyzed for survival. Adequacy of dialysis was analyzed in all existing patients in 1993 to 1994. The overall patient survival was 93%, 71%, and 57% at one, three, and five years, respectively. The three-year survival rate was 40% for diabetics and 78% for nondiabetics. It was 86%, 85%, 64%, and 43% for patients aged <35, 35 -50, 50 -65, and over 65 years, respectively. The mean weekly KT/V of 201 existing CAPD patients was 1.76, and creatinine clearance was 57 Uweek/1.73 m2. KT/V by dialysis was only 1.57. The age and disease-adjusted survival in our center was comparable to centers that used standard four 2-L exchange regimes, despite a substantially lower mean KT/V and creatinine clearance (CrCI).