Liver transplantation in HBs antigen (HBsAg) carriers

Liver transplantation in HBs antigen (HBsAg) carriers Prevention of hepatitis B virus (HBV) recurrence by passive immunization*

Liver tranrplantvtion in HBr-antigen (HBsAg) po?nive allograft recipients is associated with a high risk of HEW recurrence ronw time nfter surgery. So far, results of mdasutes to prevent recurrent HBV-infection by means of treatment with mterferon. hepatitis B vaccination and short-term passive immunization with hepatitis B immunoglobulin (HEilg) or monoclonal antibody to HBsAg (anti-HBs) have been disappointing. In the present study the results of long+nn, antiH!3s monitored passive immunization

with HBlg is reported. In 23 HBaAg.positive liver transplant recipients att anti-HBs

level of 5 100 W/l was toaintained for 6 or 12 months, respectively. The rate of recurrent infection was found to be less than 20% under HBlg suhstltution. whereas 11 graft recipients with no or only short-term HBlg prophylaxis were reinfected by moi!!h 15 after :ransplanxtlon. HBV recurrence was associated with chronic liver disease and recurrent cirrhosis in the all”g~~ft.

In recent years. arthotopic liver transplantation has proved a promising therapeutic oplion in the msnagement of sod-rtye :%LI. d,sea,e. An increasing number of potential trawplant candidates are recruited from patients wi!h ctrrhosis due to chronic infections with hepatitis B.

Pdents

hepatitis C (XV: rod delta hepatitis. However, liver transpiantation if, patients with chronic wal hepatitis is zssokk?? .x!h P high risk of recurrep.! infection some tmle af1sr s:qery (1-3). The ihdlcarion for liver grafting in t&E g-posttive candidates is hence controvrrsihl. For a long tirx, a carrier

course of 34 patienrs was evaluated in the present investigation. Patients considered for evaluation were those who had survived tne operation for at least 3 months or m whom HBV infection had already recurred within the first 3 months after sorgety. These were 29 males and five females aged i~om 13 to 62 years old (f = 38.2). Five patients (gl:ft numbers (GN”) 55-175) were transplanted from March 1982 through Srpierrioer 1985. Nine patients (ONo 229-2ES) underwent surgery st some point from June 1986 to Zbmag 1987, and in 20 parients (GN” 327506) liver transplantation was performed from September

state of HBsAg was regarded as a contraindication to transplamauon (4). In the present study, we report the outv~mc of HBsAg-positive liver transplant recipients attcr long-term, high-dare HBlg treatment to prevent HBV infcctioq ofthr. graft.

From November 1972 to October 198”. 519 liver tm”s~ pbwtot~ons were performed in 447 patients. These includ:d 46 !!&.4g-positive transplants recipients. The

1987 to September 1989. Indications for liver grafting were hepatocirrhosis in 19 pat~enrs. hepatocellular carcinoma in cirrhosis in II patients, hepatocellular cariiilosu without cirrhosis in one patient. fulminan; iiier failure m

the individual %ores bcforc and after reappearance of HBsAg in the wum or the discontinuation of HBtg prophylaxls.

two patients and a Budd-Chiari syndrome in one patient. The selection of patients for this trial was only based

Hepatrtrr B ~mmrrnoglobirlinprnphylaris

upon preoperative

serological

presence ol HBsAg

ine-

speclive of other HBV serum markers.

ative serological

HBV marker

Funher preoperprofiles were HBV-DNA

Ag

and HBe antigen (HBeAg) in four patients. HBe without demonstration of HBV-DNA in ten patients, HBVDNA and antibody to HReAg (anti-H&) in two patients. anti-HBe without detection of HBV-DNA in twelve patients and neithel HBV-DNA nor HBeAg nor anti-HBc in six parients.

Materials and Methods Detemination of the erryme activities of alanine aminotransfera~e (ALT), aspartate aminotransferrw (AST), y-glutamyt transferare IGGT). glutamate debydrogenase (GLDH), alkaline phosphatase (ALP) and cholinesterase

(CHE)

electrophoresis HBV markers

were performed with stxndard methods. HBsAg, HBeAg, anti-HBs and anti-HBe

in senon

as well a biliruhin.

and

were measured with radioimmunoassays (Au& HR. AusabR, Abbott HB@, Abbott Laboratories, Chicago, !T_, U.S.A.). Anti-HBs concentrations in the sewn were calculated with the formula spaified by Hcllingw et al. (5). HBV-DNA was demonstrated by the HepPrubrTM (GIBCO/BRL, Life lschnologjes, Eggenstein-Leopoldsrafen, F.R.G.). The limb of detection of the method was 0.3.10’ HBV genomesi5Oyl Antibodies to HCV (anti-HCV) determmatiorts were &lone with an ELlSA technique (Ortbc? HCV Ant;budy ELlSA Tat System GRTHO Diagnostic Sys:omr, Neckargemiind. F.R.G.). HBV serology mcludiog HBV-DNA testiog was performed in all PAtients preoperatively and at &month intervals at lerst during follow-up after surgery. Liver bmpsies ad iiver explants were appraised htstologically by one of the authors (Ch.W.) wtthout knowledge of the biochemical and HBV serology Zndings. Liver biopsies after transplantstion wxe performed according to clinilrrl needs m 13 patients. The scoring sysrem descrfhed by Knodell et al. was applied for evaluation of toe histological activity of chronic hepatitis (6).

Enzyme activities were evaluated by means of trend analysis using the media,, titter for the 6-mouth intervals. ?he Cbi-square test was applied for testing s;gnificance of

A polyvalent HBIg preparation obtained from anti-dclta-negative donor 5era after native HBV infection (Hepatee? Biotest Ltd.. Frankfurt/Main. F.R ‘: for passive xnaumzation. The anti-HBs content was 5o 1Uiml. Antdwdy to pre-s, antigen (anti-prc-s,) could also be detected in low concentrations by Western blot imalysis.

)wasused

HBlg uas ndministered intravenously according to thrcr dtfferent >cbedules in n chronological sequcncc of rransplantaaons. In the first series (GNo 55-175) F’Xpatlents received HBlg only m the anhepdtx phzsc oi sw ge’y. The doses administered ranged from 24.10 to 128 000 IU (.t 32 000 IU) of anti-HBs. Neutralization of the tuta’ nmounr of arculating HBsAg roughly estimated from the preoperawe serum HBrAg ~oncentrati~ 1s CUESnot teesible. In eleven bvec graft recipiems (sxies two GNn 229-2851 HBIg treatment with 10 MKJ IU anti-HBs was started in the anhepatic phase. The same dose was admin. istcred every day for the first 8 days nfter transplantaticn Further HBlg substitution with 10 IWO III anti-H& was continued accordmg to the an!&HB!. bloo:‘ievel An antikiBs level of at least 100 IUII was mnintaioed in :te serum for 6 months. Monitoring for anti-HBs serum c:ncentranon was performed once per rn0”‘h. The mean a”%H& dose per paoem was ‘11 u(x) IU. In another I2 indwiduals (series three, GNo 327-506) passive immunization with HBIg followed *he same scixduie as applied to the previous group of 11 patients except for two modifications: anti-HBs blood leveis of IQ0 LUil were mamtained for 12 months and HBV-D.i.4.posirive transplaot recipients each received 40 1% iU antiHBa per day for the iirst 8 da)s after operation. in this qoup the mean dose of anti-HBs per patient was 141 COO IIJ Five patxrtr from series three drd not nxeivc Hi3Ig. They were recruilzd by thence d,;e to lack of HBlg sueuly and sewed as comrols. Shortage of HBlg also determinated trea,men, prematurely according to the protocc! of patient srnes one or two in recipients

.I YI.AT.c.

with GNo 480, 385

The propmm ci recurrenti_fBV infection m the vxious series of investigations is shown in Fig. I. 111all patients ;vho bad not received any passive ;mmunization or

92

in whom hepat,c peared

the HBlg phase

in the

tation. On tients

was ody

or sorgiry, serum within

the other

under long-term

hand,

administered during the an-

Ad”-DNA

and HBSAAg reap-

1 to ‘5 months HBV

suhhtutim

an.3

recurrence

of HBlg

transptanrates

inpa-

and anti-HBs

msintmance levels of alOO I’d!1 *zls fad to 5.. very low They amounted to 18 and 25’5, respectively, after 6 or 12 monthsoi prophylaxis. In both groupsthe frequency of recurrent Infections increased after disconttnuation of HBIg administration. Twenty-four months after trans. plantation, the sera of thrre out of seven patients it, tht: group treated for h months and the sera of four out of elghhlpat~nrs m the group treated for 12 monthr were still

negatiw for HBsAg and HBV-DNA. It nay be assumed that rhey have defmmvely eliminated the vision. The longest pernodof follow-dp of a rrawplant recipient with succerrful prevention of HBV recurrence in our serieb w.sSZ months. The preoperative HBV marker rnfik ir! the serum is a crucial Indicator for HBV recurrence. Despite H91g maintenance prophylaxis, recurrent infection was prevented m only one ci nine individuals in whom HBV-

HEPATITIS B AND LIVER TRANSPLANTATION other hand, HBV recurrence was surzssfully prevenrrd by long-term treatment with HBlg in ten out of 14 HBVDNA-negative graft recipients with or without demonstration of anti-HBe in the serum While on HBlg substitution, all patients in this group remained HBsAg-negative (Table 1). The clinical significanceof recurtent HBV infection after liver transplantation was analysed on the basisof mortality, the results of liver function tesf~and the findings of liver histopathology. Out of the 34 patients evaluated. ten have died. All of these patients belonged to the group of 24 patients with HBV recurrence (42%). The cause of death was fldt directly related to the recurrence HBV infection in any patient. Five individuals died from tumor recurrence of hepatocellular carcinoma, two patients from septicemia, one patient from cerebral hemorrhage and another patient from necrotiring pancreatitis with respiratoryfailure. None of the 10 patients without HBV recurtence died. The period of follow-up after transplantation was more than 18 months in all ten patients. Follow-up documentation of aminotransferase activities appropriate for evalu-

93 ation was available in 19 graft reciplentr. Fig. 2 shows the course of AST and ALT in ten patients with recurrent HBV mfection 3 months prior to ad 3 mrnths nf?er reappearancc of HBnAg and in nine tranrplaat rccipiefits without HBV tzcurrence befwe and after dkontinuation of HElg prophylaxis. Presenceof HBsAg in serum was associated with a signifirrnt rise of aminatransferaseactivities in nine out of ten patients. In one patient. liver enzyme actwities were already elevated at :he time of HBsAg recurwvx Retrospectiveanalysis of sewn samplesobtained from :his individual prior to transplantation revealedantiHCV positivity. The antibody disappeared from the serum immediately after wrgery. but was again detected by the ttme HBsAg reappearedin the serum. In transplant recipients without recurrent HBV infection. a rise of aminotransferax activity was not observed upon discontinuation of HBIg prophylaxis. Even in this group of patients. the only exception involved a preoperatively anti-HCV-positive irdividual who experienceda relapse of chronic hepatitis C infection after the operation.

h

I I I t

150 \ 50

‘:

--T----l

L

-3 montns

0 months

3

HBsAg

AST

during

the follow-up.

HBs antigenemia. significantly

T

currence (Fig.

All

developed

persistent

The mean enzyme activities

from transplant

3). Aminotransferases

from

transplantation.

13 patients.

HBV

remained

above the normal range. indicating chronic liw After

differed

recipients without

disease.

18 liver biopsies were avei!able

Five biopsies were obtained

HBsAg-negative

re-

elevated

patients

taken

from fire

5 to 24 months

after

transplantation.

All showed nonspecific liver lesions with-

out histological

signs of chronic

hand, the histological

hepatitis.

examination

00

the other

of the last follow-up

biopsies in eight patients with HBV

recurrence

revealed

‘acute hepatitis’ in one individual,

‘chronic persistent hep

atitir’

aggressive hepatitis’

in two subjects.

‘chronic

in

three recipients and ‘cirrhosis’ in two patients. The results are shown in Fig. 4. The shortest period from reappearance of HBsAg

in the serum and a histological

diagnostn

of cirrhosis was 8 months.

In the presence of circulating

HBsAg,

tion entai!? a ;
liver transplanta-

infection

of the hepatic

allograft some time after surgery. The first report of HBV recurrence after liver grafting was presented by Torisu et al. in 1971 (7). The still limited experience available today

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Fh.4.H,~,ulugical lnchngi of13HBv,g-poswe liver transpliln, rcapnta wth and without HB”

18

21

24

months

recurrence AH, acute hepatitis:NH,.. nonspenlic hcpatr lcrionr: CPH. chronic persistenthepatitis:CAH. chronic aggressivehepatitis:and Cf. cirrhnsia.The solid line representsHEsAgnegativeserumand the dotted line HBsAg.positive serum.

95 indicates that in the absence of prevenrive measures HBV infection will tecor in the vast nvaJority of HBsAg-positiw liver transplant recipients (l--3,8,9). All patients of our series who were not trcatcd with y-globubn or who received wtly H3!: during the anbepatic phase experienced recurrent HBV infection vithin I to 18 months after surgery. Various attempts to prevent HEW recurrence in trans. plant recipients have been discouraging. Human intetferott. a substance with antiviral and immunomodulatory properties,

has been shown to suppress

HRV replication

(10-12). The useof a-interferon to treat chronic hepatitis B has proven beneficial in a number of non-immanor~lppressed Caucasians (13-15). So far, hoaever. interferon therapy in immunocompromised patients has beer: far :a effective. This also appears to be true for liver graft recipwtts. A first trial with a-interferon for prwention of recurrent HBV infection after liver transplantation was unsuccessful(i6,t7). Furthermore, ioterferons increase the expression of HLA class 1 antigens on cell surfaces. This effect has also been described for the hepatocyte membranes (18.19). which gave rise to the fear that interferon treatment might promote

the risk of rejection

in transplant

re-

to a prolongation of the incubation period, as is srcn with hepatms 6 following passwc post-exposure immunoprophylaais (25.27). A similar observation, delayed recurrence of HBV mfection after perioperative g-globubn treatment. has been described by Carey and has ca-workU\(9). Howrvrr. it appears more probable rhat a recurrent HBV mfectior. ;F cai;rsd bf viros particles derived from rxtrahrpatic replication (Jl). Extrachromonomal HBVDNA. tranrcripts, translation products such as HBs and HBc antigens and virion-like JXme particles have been detected in non-hepatic tissues (?2-34). As a result themfection of the graft by hepatitis B virions produced m cells from outside the liver is rendered possible. Fo: the moment I: is still uokovwo wbitbc: sxtrahepatic, small-scale production of k!BV in liver transplant recipients can be detected by demonstrstiua of HBV-DNA by usmg more recent technques such as polvmerase chain reamoo or msitu hybriduation. and whether patients with or without a risk for al&aft infection may be differentiated prior to termmation of HBlg treatment. After transplantation. recurrent HBV infection is assoctated utlh a poor prognosis (8). Mortality in our patients, however, was not directly attributable to the Infection of

cipients.

the transplant.

Hepatitis B vaccination with ‘pre-s’- and ‘s’-containing antigens is rarely efficient in immunocomgr.~;i&ed patients (20-23). In agreement with findings of Rizzetto et al., we were not able to induce an anti-HBs response in liver transplant vaccinees in the first weeks after trots-

liver graft recipients with either no or short-term passive immuniza:icn. was not obsuv
plantation (24). However, 8 protective antt-HBs swum level may be attained passively by administration of polyclonal HBfg (25). HBIg treatment appears to be an effective prophylactic measure for medical staff after accidental needle-stick exposure and for spouses exposed to acute hepatitis B (25-27). In our patients, the rate of recurrent HBV infections was less than 20% by maintaining an anti-HBs blood level of ICQ WI for at least 6 months. and a final disappearance of serological sigcr indicating active infection was attained in transplant recipients with a preoperative sero-status of low HBV infectivity even after dismntinuation of HBIg substitution. These observations are in agreement with those of CoIledan, Reyner and Ferla (28-M). Once patients were on long-term trea:mcct with HBIg, definitive disappearance of viral DNA or translation products from the serum could not be discerned from citber the preoperative nor postoperative serological HBV marker profiles. Recurrence of infection after HB,g prophtlaxir

even for over I% months might be attributed

Fulminant

hepatitis.

which can occur in

viduals after kidney transplantation (35-39). Despite this mild subclimca, picture with slight biochemical abnormalities, the disease ran a chronic coarse. Chronic aggressive bepatnir on biopsy developed rapidly in five patients. wth recurrent cirrhosis in tw of them. On the basis of these data. it is crucial that liver transplantation in HBsAg-positive recipmtts be associated with a treatment procedure for successful preven:ion of recurrent HBV infection in the hepatic allograft after surguy. Today. long-term hepatitis B immunoglobulin substitution with maintenance anti-HBs serum levels of at least LOOW/I provides a useful prophylaxis for patients wtth a low replic?.tive srate of HBV. The postsorgtcal management for HBV-DNA-positive liver transptlsot rcctpients still remams unresolved. The use of potential monoclona, ant+HB ‘pre-s‘ and ‘s’ prrparations may perhaps be more beneficial (40) and may help to reduce the tremendously hzgh cost of polyvalent human HBlg prophy,ax,r today

the anti-pre-s was supported We nre g,atcful of Hygiene.

to Profcssso, Wolfram

Univcmity

of G6tti”gen

Gerlich.

Institute

fo, determination

Forschergruppe

content

of the HBIg

by the Deutsche

preparation.

This study

Forschungsgemeinrchaft.

Organtransplantztion.

project

AS.

of

Z DC&S AJ. Jafk R. Shcnha” DG. e! al. Recurrent hcpalitis B I” live, all”~,“ft ,ccm~c”ts: ddfcrcntiatio” bclwcrn virnl hcp_

27 G,ady GF. Lee “A. “eparirir B im”wne glob”“” - P,C”C”,iD” al beptiti~ from accidcntat exposure among medical personnel. N E”gl J Med ,975; 293: 1067-78. 28 Cokdan M. G,c”dele M, Gridetti B, et al. Lo”@,“, ,es”br ai te, live, tmnsplsntsti”” in B and deba be~atiris. T,a”s,,la”t Roe 19Lw21: 2421-3.

3: itiassi E, Romct-Lemonnc IL, !&sex M. MELIOS MT, Harclrine WA. Evidence of cxi,acbm,“osomal form” of hepatitis B viral DNA in a bone marrow c~Iw:c obtained from a patient recently infected with bepad,ir R vims. Pmc Watt Acad Sci USA 1984: St: 3526-8. 31 Romer-Lcnwnne ,I.. McLane MC=. Elksi E, “asetd”e WA, Awea, J, Essex M. Hepatitis B viw infecdo” in cultured human lympbobtasroidcett.. Swnce ,983; 221: 647-9. 35 Ha,“cu JD, Zetdis 03. Parfrey PS, et PI. Hepatitis B disease in dialysis and ,,a”rpla”t paticna. Transplantation 1987: 4:: 369-76. 36 Miille, R, wonigei, K. Babb”ann J. et al. Significance ol*us,,alia antqe” in tnticntr af,e, Lidney ,,anspta”ta,io”. Kli” Wocbenwb, 1971;49: 768-9. 37 Schmidt E, Schmidl FW. Clinical putbotogy ofwral hepatitis. t”: Deinbanlt F. Dcinbard, J. edr. Viral Hepaddr: Laboratory and Cli”KalScie”cc. New York Marcel Dekb,, ,983: 411-87. 38 DusheikoG. Song E, Bowyc,S,e, at. NJlurslbirtoryafbepatitir B virus infecdo” in renal tramplan, recipientr- a bftce”.yeartot. lowup. Hepatology ,983; 3: 330-6. 39 Parfrey PS. Robes RDC. Hutcbinro” TA. et at. The clinical and