Preventing HBV Recurrence in HIV/HBV Coinfected Patients Undergoing Liver Transplantation

Preventing HBV Recurrence in HIV/HBV Coinfected Patients Undergoing Liver Transplantation

Use of hepatitis B immune globulin (HBIG) and antiviral drugs such as lamivudine (3TC, Epivir-HBV) can help prevent re-infection of the new liver after transplantation in patients with hepatitis B virus (HBV) infection. Pre- and post-transplant outcomes among HIV/HBV coinfected individuals, however, have not received extensive study.

Infection with lamivudine-resistant HBV may increase the risk of liver-related death before transplantation, as well as prophylaxis failure following a transplant. To explore this issue, Norah Terrault, MD, and colleagues from the University of California at San Francisco evaluated the effect of lamivudine resistance on pre-transplant survival and post-transplant outcomes in 35 consecutive HIV/HBV coinfected patients referred for liver transplantation between July 2000 and September 2002.

Results

At the time of referral, the median CD4 cell count was 273 cells/mm3 and the median MELD score (a measure of liver disease severity) was 14.

67% of patients had evidence of lamivudine-resistant HBV.

Among the referred patients, 26% were listed for transplantation and 29% were not listed due to relative or absolute contraindications:
26% were considered too early for liver transplantation;

9% were considered too sick for liver transplantation;

11% died during transplant evaluation.
Of the 9 listed patients:
4 remained listed;

1 died 18 months after referral;

4 (11% of the total) received liver transplants 3 to 40 months after listing.
Of 17 patients who were evaluated but not listed, 5 died; all deaths were liver-related (P = 0.38 compared with listed group).

After a median 33 months of follow-up, all the HIV/HBV coinfected patients who received transplants were HBsAg negative and had undetectable HBV DNA while on prophylactic therapy with HBIG plus lamivudine, with or without tenofovir (Viread) or adefovir (Hepsera).

Conclusion

In conclusion, the authors wrote, "Late referral and the presence of [lamivudine-resistant] HBV pre-transplantation are common in referred HIV/HBV [coinfected] patients. In HIV/HBV coinfected patients undergoing [liver transplantation], HBV recurrence is successfully prevented with combination prophylaxis using HBIG and antivirals."

08/01/06

Reference
N A Terrault, T Carter, L Carlson and others. Outcome of patients with hepatitis B virus and human immunodeficiency virus infections referred for liver transplantation. Liver Transplantation 12(5): 801-807. May 2006.