Increasing applicability of liver transplantation for patients with hepatitis B-related liver disease

Abstract

Liver transplantation in patients with hepatitis B has been under discussion for 20 years because of inferior results without reinfection prophylaxis; therefore, we analyzed our overall experience with liver transplantation in hepatitis B patients with immunoprophylaxis, particularly the influence of the available antiviral treatment in different periods. From 1988 to 2000, 228 liver transplants in 206 hepatitis B patients were performed. Indications were acute liver failure (10%), hepatitis B virus (HBV) cirrhosis alone (67%) or with hepatitis D virus (HDV) (13%), or hepatitis C virus (HCV) coinfection (7%). All patients received long-term immunoprophylaxis (anti-HBs > 100 U/L). HBV DNA-positive patients were treated before and after surgery with famciclovir or lamivudine since 1993 and 1996, respectively. Since 1993, antivirals also were used for HBV reinfection. The 1-, 5-, and 10-year patient survival rates were 91%, 81%, and 73%. In patients with hepatocellular carcinoma (HCC) (60% 5-year survival, P < .01) or HBV reinfection (69% 5-year survival, P < .01) survival was significantly impaired. Those with HDV or HCV coinfection had a slightly better survival than with HBV monoinfection (P > .05, not significant). Preoperative positive HBV DNA (hybridization-assay) test results were associated with a slightly impaired patient survival (78% 5-year survival, P > .05, not significant versus DNA-negative). Preoperative positive hepatitis B e antigen (HBeAg) predicted significantly worse survival (P < .05 versus negative HBeAg). Graft loss caused by reinfection was most frequent before the availability of antiviral drugs. Two-year patient survival increased from 85% in era I (1988-1993) to 94% in era III (1997-2000, P < .05). The 2-year recurrence rates in these 2 periods were 42% and 8% (P < .05). In conclusion, excellent long-term results can be achieved in hepatitis B patients after liver transplantation with modern strategies, and survival rates are similar to other indications. Based on our experience, hepatitis B patients, including those with active viral replication, should not be excluded from liver transplantation. (HEPATOLOGY 2002;35: 1528-1535.) B ecause of a severe donor organ shortage, indications for orthotopic liver transplantation (OLT) with significantly lower than average long-term survival are discussed with controversy. Hepatitis B virus (HBV)-associated liver cirrhosis, especially without the availability of immunoprophylaxis and antiviral agents, often was associated with HBV recurrence after transplantation, often with rapid progression to cirrhosis. Therefore, hepatitis B was considered a contraindication to liver transplantation in many centers. On the other hand, passive immunoprophylaxis with hepatitis B immunoglobulin (HBIg) has been shown to substantially reduce recurrence rates and to improve the outcome after OLT. 1,2 Still, a significant number of patients between 15% to 60% develop hepatitis B recurrence and partially suffer from graft failure despite anti-HBs titers kept at 500...

High Viremia, Prolonged Lamivudine Therapy and Recurrent Hepatocellular Carcinoma Predict Posttransplant Hepatitis B Recurrence

“…The level of viral replication before transplantation is a wellestablished predictor for prophylaxis success, regardless of the prophylactic protocol (7,8,(18)(19)(20) (9,21), while others found no association between HCC prior to OLT and posttransplant recurrent hepatitis B (7,18,22,23 …”

The detection of (total and ccc) HBV DNA in liver transplant recipients with hepatitis B vaccine against HBV reinfection

“…1 Liver transplantation (LT) is the most effective therapeutic option for HBV-infected patients who have acute or chronic liver failure and/or primary liver cancer, and the outcomes of LT have been reported to be as good or even better in HBV-infected patients than in non-HBV patients. 2,3 This success has been attributed to the prophylactic strategies against HBV reinfection after LT. The combination prophylaxis with antiviral agents and HBIG reduces the HBV recurrence rate to 5% at 5 years, which is now almost universally adopted by most transplant centers as the golden standard for the prevention of HBV reinfection.…”

Treatment of hepatitis B and C after liver transplantation. Part 1, hepatitis B

“…In 206 patients receiving adequate immunoprophylaxis, results of OLT for HBV infection in Berlin are similar to those achieved with other indications. Survival rates at 1, 5 and 10 years were 91%, 8 l % , 73%, respectively [93]. In the multivariate analysis for patient survival, presence of hepatocellular carcinoma and HBV recurrence was associated with lower survival rates.…”