Disclosures: Gun Hyung Na, Dong Goo Kim, Jae hyun Han, Eun Young Kim, Soo Ho Lee, Tae Ho Hong, Young Kyoung You, and Jong Young Choi have no conflict of interest or financial ties to disclose.
Prevention and risk factors of hepatitis B recurrence after living donor liver transplantation
Article first published online: 19 DEC 2013
© 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
Journal of Gastroenterology and Hepatology
Volume 29, Issue 1, pages 151–156, January 2014
How to Cite
Na, G. H., Kim, D. G., Han, J. H., Kim, E. Y., Lee, S. H., Hong, T. H., You, Y. K. and Choi, J. Y. (2014), Prevention and risk factors of hepatitis B recurrence after living donor liver transplantation. Journal of Gastroenterology and Hepatology, 29: 151–156. doi: 10.1111/jgh.12403
- Issue published online: 19 DEC 2013
- Article first published online: 19 DEC 2013
- Accepted manuscript online: 3 OCT 2013 11:18AM EST
- Manuscript Accepted: 5 SEP 2013
- hepatitis B immunoglobulin;
- hepatitis B virus;
- hepatocelluar carcinoma;
- liver transplantation;
- nucleos(t)ide analog
Background and Aim
Without effective prophylaxis, liver transplantation (LT) for hepatitis B virus (HBV)-related liver disease is frequently complicated by severe and rapidly progressive HBV recurrence. The combination of low-dose hepatitis B immunoglobulin (HBIG) and the new nucleos(t)ide analog, entecavir, as prophylaxis for HBV recurrence after living-donor LT (LDLT) were analyzed.
A total of 315 patients with positive hepatitis B surface antigen underwent LDLT at our transplant center between July 2003 and December 2011. Our protocol for post-transplantation HBV prophylaxis was a combination of low-dose HBIG and nucleos(t)ide analog.
During a median follow-up period of 49 months post-transplant, 10 patients (3.2%) had HBV recurrence, which was significantly related to hepatocellular carcinoma (HCC) at transplantation (P = 0.041) and post-LT antiviral agent (P < 0.001) in multivariate analysis. The level of HBV DNA and hepatitis B e antigen state at transplantation were not significant factors for HBV recurrence (P = 0.342 and P = 0.802, respectively). In 170 patients with HCC at LDLT, HCC recurrence was significantly related to HBV recurrence (P < 0.001). Among 10 patients with HBV recurrence, three are alive and two had lost hepatitis B surface antigen. The remaining seven patients died of HCC recurrence.
The combination of low-dose HBIG and nucleos(t)ide analogs is safe and effective for HBV prophylaxis after LDLT. As a post-LT antiviral treatment, entecavir is more effective than lamivudine. HCC at transplantation was significantly associated with HBV recurrence. HBV-related HCC patients who undergo LDLT require close virological monitoring.
Hepatitis B virus (HBV) is a leading cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC) in Asia and is responsible for approximately 500 000 deaths per year worldwide. Liver transplantation (LT) is a treatment of choice for patients with end-stage liver disease and selected patients with HCC. The HBV recurrence rate after LT is greater than 80% without any prophylaxis, and HBV reinfection may lead to rapid disease progression and early graft loss. Prevention of HBV recurrence after LT is essential in HBV-related patients. In recent years, advances in management of chronic hepatitis B in liver transplant patients have been made. Long-term treatment with hepatitis B immunoglobulin (HBIG) was associated with a reduced risk of recurrent HBV infection and reduced mortality. Since the introduction of lamivudine, a nucleoside analog that inhibits HBV replication, the HBV recurrence rate has been reduced to less than 10%. Recently, new antiviral agents have been developed showing better results. The combination of long-term HBIG and nucleos(t)ide analogs is currently the standard treatment and has effectively reduced HBV recurrence rates. To date, there have been several reports regarding the prevention of HBV recurrence after LT. However, most comprised a small study population and a short follow-up period, and few studies included new antiviral agents such as entecavir and tenofovir. Recently, the development of more potent antiviral agents, such as entecavir and tenofovir, and introduction of new prophylactic strategies, including HBIG minimization and withdrawal, and HBIG or nucleos(t)ide monotherapy, has occurred due to the high cost and inconvenience of life-long HBIG treatment.[5, 6] However, a majority of the new prophylactic strategies also comprised a small study population and short follow-up period. Although HBV recurrence rates were relatively high in these reports, clinical outcomes such as recurrent graft loss and graft failure showed excellent results. The new prophylactic strategies will be hopeful, but further clinical experience in larger cohorts is needed to make a conclusion. Therefore, reassessing the current standard prophylactic strategy that includes the combination of long-term HBIG and nucleos(t)ide analogs is necessary. Also, research on the new antiviral agents as a standard prophylaxis for HBV reinfection after living-donor LT (LDLT) in a large study population and with a long follow-up period is necessary.
In our institution, the protocol for post-transplantation HBV prophylaxis is the combination of low-dose HBIG and nucleos(t)ide analogs. In the present study, we assessed the efficacy of our protocol by determining the HBV recurrence rate and its contributing factors. Additionally, we evaluated the relationship between HBV and HCC recurrences, and the treatments and outcomes of HBV recurrence in patients who underwent LDLT at a high-volume single transplant center.
A total of 315 patients positive for hepatitis B surface antigen (HBsAg) underwent LDLT at our transplant center between July 2003 and December 2011. The medical records of the patients were reviewed retrospectively. This study was approved by the Institutional Review Board.
Protocol for post-transplantation HBV prophylaxis
All patients were treated with a combination of HBIG and nucleos(t)ide analogs for prophylaxis of HBV recurrence and were given 10 000 units of HBIG intravenously during the anhepatic phase, which was followed daily for 7 days and then every month for 6 months after LDLT. Afterwards, the patients were given 4000 units of HBIG (low dose) intravenously every month. Some patients were given 10 000 units (high dose) intravenously every month after postoperative 6 months according to physician preference. A target hepatitis B surface antibody (HBsAb) level was 200 IU/L in our protocol. We increased the dose of HBIG to 10 000 units in the cases of under 200 IU/L of HBsAb level. Administration of antiviral agent was started 3 days after transplantation. All patients were taking lamivudine or adefovir until 2007, and then took entecavir. Patients suspected of HBV recurrence were reassessed for viral markers and HBV DNA level. Patients diagnosed with HBV recurrence were started on adefovir or entecavir treatment based on their previous antiviral agent and antiviral drug resistance mutation test.
Post-transplant serological monitoring
Patients were followed weekly after hospital discharge until stable and then monthly for the first year, every 2 months for 5 years, and then every 3 months. Standard liver function tests were monitored on each follow-up visit. Viral markers, including HBsAg, HBsAb, hepatitis B e antigen (HBeAg), and hepatitis B e antibody, were measured monthly using the electrochemiluminescence immunoassay; HBV DNA was tested every 3 months. Serum HBV DNA was measured with branched DNA assay (Siemens Healthcare Diagnostics, Eschborn, Germany; lower limit of detection: 2000 copies/mL) until May 2006 and then was measured with a highly sensitive real-time PCR assay (Abbott, Chicago, IL, USA; lower limit of detection: 34 copies/mL). HBV drug resistance mutations were detected using the restriction fragment length polymorphism method until September 2006 and then a sequencing method thereafter (Siemens Healthcare Diagnostics). HBV recurrence was defined as the reappearance of circulating HBsAg after transplantation with or without measurable HBV DNA.
The immunosuppression regimen consisted of the following three agents: tacrolimus or cyclosporin, mycophenolate mofetil (MMF), and prednisolone. The dose of tacrolimus was adjusted to maintain 7–10 ng/mL levels for the first postoperative month and 5–7 ng/mL thereafter. The dose of cyclosporin was adjusted to maintain 100–150 ng/mL levels for the first postoperative month and 50–100 ng/mL thereafter. Steroids were withdrawn 1 month after surgery, and MMF was withdrawn 6 months after surgery. An interleukin-2 receptor blocker was administered on both the day of the operation and the fourth postoperative day.
Continuous variables were reported as means ± standard deviation. To evaluate the risk factors for HBV recurrence, univariate analysis was performed using the Kaplan–Meier method and evaluated using the log-rank test. Candidate predictors associated with a P value < 0.2 by univariate analysis were entered into a multivariate analysis using Cox regression analysis. Overall survival and disease-free survival were calculated using the Kaplan–Meier method and evaluated by log-rank test. Statistical analysis was performed using SPSS (Chicago, IL, USA) 18.0 for Windows. A P value < 0.05 was considered to indicate statistical significance.
Characteristics of patients
Among the 315 patients, 244 (77.5%) were male and the mean age was 50.4 ± 7.8 years; 170 patients (54.0%) had HCC. At transplantation, 127 patients (40.3%) were HBeAg-positive, 236 patients (74.9%) were HBV DNA-positive, 131 patients (41.6%) had a high viral load (HBV DNA > 5 log10 copies/mL), and 114 patients (36.2%) were both HBeAg and serum HBV DNA-positive. A total of 242 patients (76.8%) received antiviral treatment before transplantation consisting of lamivudine and/or adefovir in 170 patients (70.2%) and entecavir in 72 patients (29.8%). Mean duration of pretransplant antiviral treatment was 7.2 ± 11.3 months (range 1.0–60.0 months). After transplantation, all patients received a combination of HBIG and nucleos(t)ide analogs as per protocol. Fifty-three patients (16.8%) received lamivudine and/or adefovir, and the remaining patients received entecavir. Most of the patients (82.2%) were treated with low-dose HBIG according to our protocol. The median follow-up period was 49.0 months (range 1–114.0 months) (Table 1).
|Mean age (years)a||50.4 ± 7.8|
|Male, n (%)||244 (77.5%)|
|MELD scorea||15.9 ± 9.4|
|GRWRa||1.23 ± 0.39|
|Emergent transplantation (UNOS I and IIA), n (%)||37 (11.7%)|
|Concomitant HCC, n (%)||170 (54.0%)|
|HCC recurrence after LDLT, n (%)||24 (14.1%)|
|Viral status at transplantation, n (%)|
|HBeAg (+)||127 (40.3%)|
|HBeAg (+) and HBV DNA (+)||114 (36.2%)|
|HBV DNA > 5 log10 copies/mL||131 (41.6%)|
|Pretransplant antiviral treatment, n (%)||242 (76.8%)|
|LAM and/or ADV||170 (70.2%)|
|Duration of antiviral treatment prior to LDLT (months)a||7.2 ± 11.3|
|Post-transplant antiviral treatment, n (%)|
|LAM and/or ADV||53 (16.8%)|
|Post-transplant high-dose HBIG, n (%)||56 (17.8%)|
|Immunosuppression, Prograf : Cyclosporin, n (%)||225 (71.4%):90 (28.6%)|
|Follow-up duration (months)a||51.1 ± 34.2 (median 49.0, 1–114)|
HBV recurrence and risk factors
During the follow-up period, 10 patients (3.2%) experienced HBV recurrence. The mean time to HBV recurrence was 30.5 ± 26.7 months (range 2.0–75.0 months). The overall probabilities of HBV recurrence at 1, 3, 5, and 10 years post-transplant were 1.0%, 2.8%, 3.5%, and 5.3%, respectively.
We evaluated factors related to HBV recurrence. Univariate analysis showed that pretransplant HCC (P = 0.011, Fig. 1a), the antiviral agents after transplantation (P < 0.001, Fig. 1b), and HCC recurrence after transplant (P < 0.001; Fig. 2a) were associated with HBV recurrence. HBeAg status and HBV DNA status (especially HBV DNA > 5 log10 copies/mL) at transplantation were not significantly different between the two patient groups. The use of pretransplant antiviral treatment, the dose of HBIG after transplantation, and post-transplant immunosuppression were not significant factors for HBV recurrence (Table 2). On multivariate analysis, pretransplant HCC (hazard ratio [HR] 9.511 [1.096–82.541], P = 0.041) and the type of antiviral agent after transplantation (HR 18.830 [5.191–68.302], P < 0.001) were significantly associated with HBV recurrence (Table 3).
|Factor||HBV recurrence (n = 10)||No HBV recurrence (n = 305)||P|
|Recipient age (≥ 60 years)||2 (20.0%)||35 (11.5%)||0.259|
|Male||10 (100.0%)||234 (76.7%)||0.083|
|MELD score (≥ 25)||0||62 (20.3%)||0.103|
|GRWR (≥ 1.0)||8 (80.0%)||243 (79.7%)||0.929|
|Emergent transplantation (UNOS I and IIA)||0||37 (12.1%)||0.246|
|Concomitant HCC||9 (90.0%)||161 (52.8%)||0.011|
|HCC recurrence after LDLT||7 (77.8%)||17 (10.6%)||< 0.001|
|Viral status at transplantation|
|HBV DNA > 5 log10 copies/mL||3 (30.0%)||128 (42.0%)||0.342|
|HBeAg (+)||4 (40.0%)||123 (40.3%)||0.802|
|HBeAg (+) and HBV DNA (+)||4 (40.0%)||110 (36.1%)||0.970|
|Pretransplant antiviral treatment||8 (80.0%)||234 (76.7%)||0.782|
|LAM and/or ADV||8 (100.0%)||162 (69.2%)||0.165|
|Post-transplant antiviral treatment||< 0.001|
|LAM and/or ADV||6 (60.0%)||47 (15.4%)|
|ETV||4 (40.0%)||258 (84.6%)|
|Post-transplant high-dose HBIG||1 (10.0%)||55 (18.0%)||0.639|
|Post-transplant low-dose HBIG||9 (90.0%)||250 (82.0%)|
|Prograf||2 (20.0%)||88 (28.9%)|
|Cyclosporin||8 (80.0%)||217 (71.1%)|
|Factor||Hazard ratio (95% confidence interval)||P|
|Pretransplant HCC||9.511 (1.096–82.541)||0.041|
|Antiviral treatment after transplantation (LAM and/or ADV vs entecavir)||18.830 (5.191–68.302)||< 0.001|
The relationship between HBV and HCC recurrences
Among the 170 patients who had HCC at transplantation, nine (5.2%) experienced HBV recurrence. The overall probabilities of HBV recurrence at 1, 3, 5, and 10 years post- transplant in HCC patients were 1.9%, 4.2%, 6.8%, and 9.1%, respectively. On univariate and multivariate analyses, pretransplant HCC was significantly associated with HBV recurrence. HCC recurred in 24 (14.1%) of the 170 patients with HCC. HBV recurrence occurred in seven (29.2%) of the 24 patients who had HCC recurrence and in two (1.4%) of the 146 patients who did not have HCC recurrence (P < 0.001). Seven patients presented with both HBV and HCC recurrences. In four of these seven patients, HBV recurrence preceded HCC recurrence. Spearman's correlation analysis demonstrated a strong correlation between HBV and HCC recurrence times (r = 0.915, P = 0.004; Fig. 2b).
Treatments and outcomes for HBV recurrence
Overall survival was significantly reduced for patients with HBV recurrence, with probabilities at 1, 3, 5, and 10 years of 80.0%, 40.0%, 40.0%, and 26.7%, respectively, for patients with HBV recurrence versus 87.8%, 85.6%, 83.8%, and 82.2%, respectively, for patients without HBV recurrence (P < 0.001). The cause of the death in HBV recurrence group was all HCC progression. Among the 10 patients with HBV recurrence, HBV viral status at pretransplant showed five patients were both HBeAg and HBV DNA-negative, and the remaining five patients were both HBeAg and HBV DNA-positive. Six patients received lamivudine, three patients received lamivudine followed by entecavir, and one patient received entecavir as the post-transplant antiviral agent. Among the six patients with recurrence treated with lamivudine for prophylaxis, four patients were switched to adefovir, one to entecavir, and one was not treated for HBV recurrence because HCC had severely progressed. The mutations at the tyrosine-methionine-aspartate-aspartate (YMDD) nucleotide-binding locus of the HBV DNA polymerase were detected in three of four patients who were tested for the mutation. A codon change at site 552 (M552I; from a methionine to an isoleucine in the C domain) was observed in two patients, and a codon change at site 552 (M552V; from a methionine to a valine in the C domain) was observed in the remaining one patient. Four patients with recurrence treated with entecavir for prophylaxis were maintained on entecavir. Among the 10 patients with HBV recurrence, three patients are alive, and two of them have lost HBsAg. The remaining seven patients died of HCC progression.
When defining the HBV recurrence, it is more important to evaluate the clinically relevant recurrence such as graft hepatitis and graft failure than HBsAg reappearance alone. However, the HBV recurrence was defined as the reappearance of HBsAg with or without measurable HBV DNA in most previous reports, although there were some differences. Therefore, we defined HBV recurrence as with previous studies to compare the effectiveness of our protocol.
The current standard method for prophylaxis of HBV recurrence after LDLT is the combination of low-dose HBIG and nucleos(t)ide analogs over a long period. HBIG neutralizes HBsAg and binds viral particles, forming an immune complex leading to immune clearance as well as lysis of infected hepatocytes via cell-mediated immunity. However, HBIG has little effect on viral replication. Nucleos(t)ide analogs directly inhibit viral replication in hepatocytes and extrahepatic tissue. Recently, new antiviral agents were developed—these show better results. There were several studies of HBV prophylaxis using the combination of HBIG and nucleos(t)ide analogs after LT.[7-10] However, these studies had several limitations, including a small number of patients and a short follow-up period. There have been few studies of new antiviral agents such as entecavir or tenofovir, and HBV viral load at transplantation in these studies was lower than that we report here. Recently, new prophylactic strategies, including HBIG minimization and withdrawal, and HBIG or nucleos(t)ide monotherapy, have been introduced. Wesdorp et al. reported that the HBV recurrence rate in 16 patients who started withdrawal of HBIG at 6 months after LT was 6.2% in a mean follow-up period of 12 months. Stravitz et al. reported that HBV recurrence rate in 21 patients who started withdrawal of HBIG at 6 months after LT was 4.7% in a mean follow-up period of 31 months. These studies consisted of a small population and a short follow-up period. Another study regarding antiviral agent monotherapy was reported by Wadhawan et al. where 30 patients received entecavir or tenofovir monotherapy, the median follow-up period was 20 months, and the HBV recurrence rate was 37%. The HBV recurrence rates of these new prophylactic strategies were much higher than those of standard therapy. However, there were some reports about antiviral agent monotherapy without HBIG showed good results recently. Gane et al. reported that there was no HBV recurrence in 48 patients who received the combination of lamivudine and adefovir without HBIG in a mean follow-up period of 22 months. Fung et al. showed that the rate of HBsAg seronegativity and HBV DNA suppression to undetectable levels at 8 years after LT in 362 patients who received antiviral agent monotherapy without HBIG was 88% and 98%, respectively. Therefore, the new prophylactic strategies will be hopeful, but it is needed to discuss on this issue to make a conclusion.
In the present study, we assessed the efficacy of our protocol for post-transplantation HBV prophylaxis consisting of a combination of low-dose HBIG and nucleos(t)ide analogs. The strengths of the present study were the large number of patients with high viral load, long duration of follow-up compared with previous studies, and assessment of the results of treatment with the new antiviral agent, entecavir. Therefore, it will be expected that the present study is a good standard to compare with the results of new prophylactic strategies. In the present study, 10 patients (3.2%) had HBV recurrence, and the overall probabilities of HBV recurrence at 1, 5, and 10 years post-transplant were 1.0%, 3.5% and 5.3%, respectively. These findings demonstrated that a combination of low-dose HBIG and nucleos(t)ide analogs provides effective prophylaxis against HBV recurrence.
The risk factors for HBV recurrence include a high viral load (HBV DNA > 5 log10 copies/mL) at transplantation, HBeAg positivity, immunosuppression because of steroids and/or chemotherapy, mutation of the YMDD nucleotide-binding locus of the HBV DNA polymerase, and HCC. Lamivudine resistance occurs more frequently in immunosuppressed patients than in non-immunosuppressed patients. In the present study, the use of lamivudine for post-transplant antiviral treatment was an independent risk factor associated with HBV recurrence after LDLT, and HBV-YMDD mutations were detected in three of the four patients with recurrence treated with lamivudine. However, the treatment time and follow-up period between the lamivudine and entecavir treatment groups were different; therefore, a more controlled study is needed. We did not find significant relationships with HBV DNA level and HBeAg positivity, which were previously reported as high-risk factors for HBV recurrence. Except for those with HCC, only one patient had a HBV recurrence after LDLT, and so our protocol can be considered effective regardless of viral status at transplantation. Therefore, future research into the HBIG-sparing regimen in low-risk patients for HBV recurrence is necessary.
The present data demonstrated that pretransplant HCC and HCC recurrence after LDLT are significant risk factors associated with HBV recurrence after LDLT, and there is a strong correlation between HBV and HCC recurrence time. Our findings are consistent with an earlier report that pre-orthotopic liver transplantation HCC and HCC recurrence after transplantation are associated with HBV reinfection and decreased patient survival. The present study showed that overall survival was significantly reduced for patients with HBV recurrence. However, low survival rates in HBV recurrence group was because of HCC recurrence rather than HBV recurrence. Overall, among the 10 patients with HBV recurrence after LDLT, nine had pretransplant HCC. Among the nine patients with pretransplant HCC, seven had HCC recurrence and died of HCC progression. Five patients had poor prognostic factors, such as beyond Milan or portal vein invasion. Although the relationship between HCC and HBV recurrence after LT remains unclear, recent reports have demonstrated its existence. Sung et al. reported that intrahepatic HBV covalently closed circular (ccc) DNA can be a predictor of sustained virological response. Wong et al. demonstrated that HBV cccDNA is the main form of HBV DNA isolated from tissues with HCC. Faria et al. reported that detection of HBV cccDNA in HCC suggests that HBV replication in tumor cells contributes to HBV recurrence after LT. However, additional research into the relationship between HCC and HBV recurrence after LT is needed.
Although the recurrent HBV infection rate has been reduced to less than 10% by advances in the prophylactic management for HBV recurrence after LT, reports regarding the therapeutic strategies for recurrent HBV infection after LT remain limited. Adefovir, a nucleotide analog that selectively inhibits viral polymerases and reverse transcriptase, showed excellent activity against lamivudine-resistant HBV strain. Akyildiz et al. reported that undetectable serum HBV DNA levels in 77.8% and HBsAg negative-seroconversion in 11.1% of patients with recurrent HBV infection and lamivudine resistance after LT. In the present study, three patients with a mutation in the YMDD locus of HBV DNA polymerase were treated with adefovir, one patient had negative seroconversion of HBsAg, while the remaining two died of HCC progression without negative seroconversion of HBsAg.
The present study has several limitations. First, because this study was conducted retrospectively, the type and duration of prophylactic antiviral agent and the pretransplant test method for HBV DNA and viral markers used differed accordingly over time. Second, the number of patients (n = 10) with HBV recurrence was small, which limited the evaluation of risk factors related to HBV recurrence after LDLT.
In conclusion, the combination of low-dose HBIG and nucleos(t)ide analogs can be safe and effective for HBV prophylaxis after LDLT. As post-LT antiviral prophylaxis, entecavir may be more effective than lamivudine. HCC was significantly associated with HBV recurrence, and a strong correlation between HBV and HCC recurrence was identified, suggesting that HBV-related HCC patients who undergo LDLT require close virological monitoring.
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