Combined approach protects infants from HBV transmission by liver transplant

Last Updated: 2015-12-21

By Reuters Staff

NEW YORK (Reuters Health) - A regimen of hepatitis B immunoglobulin (HBIG) and hepatitis B virus (HBV) vaccine protects pediatric recipients of core antibody-positive livers from developing HBV infection, researchers from Korea report.

The use of hepatitis B core antibody (HBcAb)-positive grafts for transplantation could expand the donor pool, especially in HBV endemic areas, and previous studies have found their use to be safe so long as proper prophylaxis against de novo hepatitis B (DNHB) is employed.

For adults, lamivudine prophylaxis is recommended in this setting, whereas HBV vaccination is used most often in children.

Dr. Suk-Koo Lee and colleagues from Sungkyunkwan University School of Medicine, Seoul, investigated the long-term outcome of 41 pediatric liver transplant recipients of HBcAb-positive liver grafts under a prophylaxis regimen that consisted of HBIG during the first post-transplant year followed by intermittent HBV vaccine injections to maintain anti-HBsAb titers above 200 IU/L.

The median annual average of HBV vaccine injections was 0.8 per patient (range, 0-1.8), and four patients required no HBV vaccine injections due to persistently high anti-HBsAb titers throughout follow-up.

Twenty patients maintained sufficiently high anti-HBsAb levels with HBV vaccine and required no HBIG boosters, according to the November 24 Liver Transplantation online report.

Only one case of DNHB occurred during follow-up. It occurred 3.5 years post-transplant, when HBsAg was positive on routine serological testing. Liver enzymes for this patient remained normal during a year of follow-up, after which the liver enzymes were elevated and antiviral treatment with lamivudine was initiated. Liver enzymes normalized and HBsAg converted to negative after 16 months of treatment.

No grafts were lost due to DNHB-related events, and overall survival was 92.3% at 10 years post-transplant.

Three of six patients (not included in the study) who did not receive complete DNHB prophylaxis according to protocol developed DNHB at six, 16, and 20 months post-transplant.

"Since the cost of administering HBIG is much higher than nucleos(t)ide analogues (NUC) in most countries, it would not seem practical to use HBIG for long-term prophylaxis in pediatric liver transplant recipients of HBcAb+ grafts," the researchers note. "However, the potential risk of antiviral resistance and drug side effects is of concern, especially in this clinical setting where most clinicians prefer indefinite continuation of DNHB prophylaxis."

"These results and the affordability of HBV vaccine may outweigh the relative complexity in surveillance and provide support for the long-term use of this regimen in pediatric liver transplant recipients," they conclude.

Dr. Lee did not respond to a request for comments.

The authors reported no external funding or disclosures.

SOURCE: http://bit.ly/1IkgGfd

Liver Transpl 2015.