- Email: [email protected]
152 HEPATITIS B PROPHYLAXIS POST LIVER TRANSPLANTATION WITH TENOFOVIR OR ENTECAVIR
POSTERS Methods: Using the UK Transplant Registry liver donors and their recipients in England (1990–2008) were identified and cases of cancer among these were identified by matching their details with the Cancer Registries. Classification of donor cancer transmission risk into ‘Standard/non-standard risk’ and ‘Unacceptable risk’ was performed using the Council of Europe guidelines, 2010. Confidence intervals (CI) at 95% level are presented. Results: Of the 6743 liver transplants from 6571 donors, 6721 (99.7%) were from donors with standard/non-standard risk of cancer transmission (group 1) and 22 (0.3%) were from donors with unacceptable risk (group 2). There was no statistically significant difference between group 1 and group 2 in mean recipient age (42.2 years[CI 41.8, 42.7] and 40.0 years [CI 32.2, 47.9], p = 0.57), gender (males 54% and 73%, p = 0.08), mean MELD score (19 [CI18.8, 19.3] and 20 [CI 15.7, 25.0], p = 0.56), proportion of super-urgent transplants (16% and 14%, p = 0.77), five-year recipient survival (75% and 76%, p = 0.99) or risk adjusted hazard of death (HR 1.1 for group 2, CI 0.4, 3.4). None of the 599 recipients who developed post-transplant cancers had the same type of cancer as their donor, indicating that these were unlikely to be donor-transmitted. At 10 years from transplantation, additional survival benefit gained by transplanting livers from ‘unacceptable’ risk donors was 165 lifeyears (CI 163, 167) with an average survival of 7.5 years (CI 7.4, 7.6) per recipient. Conclusions: Cancer transmission from donor is a rare complication of liver transplantation. The classification of donors with certain cancers as having an unacceptable risk of cancer transmission appears to be unduly cautious. Selected donors in this group can safely donate livers providing valuable additional survival for the recipients with low rates (zero in our study) of cancer transmission. With careful donor-recipient selection and informed consent, safe expansion of donor pool can be achieved. 151 RECURRENCE OF PRE-EXISTING EXTRA-HEPATIC CANCERS FOLLOWING LIVER TRANSPLANTATION R. Desai1 , D. Collett1 , T. Evans2 , J. Neuberger1 . 1 Organ Donation and Transplantation, NHS Blood and Transplant, Bristol, 2 West Midlands Cancer Intelligence Unit, University of Birmingham, Birmingham, UK E-mail: [email protected] Background and Aims: A past history of cancer is a relative contraindication to undergoing liver transplantation because of the risk of recurrence of cancer. However, the extent of this risk is not fully established. The aim of this study was to assess the risk of recurrence of pre-existing extra-hepatic cancers following liver transplantation. Methods: We used the data from the United Kingdom Transplant Registry to link all liver transplant recipients (1985–2010) in the West Midlands region with the regional Cancer Registry to identify recipients with a history of cancer diagnosed before organ transplantation (excluding recipients transplanted with liver cancer) and those who developed a recurrence of cancer following transplantation. Kaplan–Meier survival estimates were used to assess the risk of recurrence of cancer. Confidence intervals (CI) at 95% are presented. Results: Of the 832 recipients, 16 (1.9%) had a history of cancer before transplantation, including cancers of breast (3), cervix (1), colon (1), leiomyosarcoma (1), leukaemia (1), lymphoma (4), kidney (1), prostate (1), melanoma (1), thyroid (1) and uterus (1). Two recipients developed cancer recurrence (melanoma and leiomyosarcoma) with a rate of recurrence within 5 years of transplantation of 19.8% (CI 0, 44.9). Both recipients with recurrence had been cancer-free for less than five years pre-transplant. In both cases, the recipients died as a direct consequence of recurrent cancer. There were no cases of recurrence of cancer in 14 recipients S68
of whom 8 underwent transplantation more than five years after the diagnosis of cancer. Conclusions: Our data suggest that a cancer-free period of 5 or more years is associated with a very low risk of recurrence of cancer in this selected cohort of patients. Because of the increasing age of recipients and higher incidence of cancer in patients with cirrhosis, more patients with previously treated cancer are considered for liver transplantation. Careful risk-benefit assessment should be adopted prior to offering transplantation to a patient who had a cancer treated within the previous five years. As the recurrence of cancer was fatal in both cases, informed consent will play an important role in clinical management and also has medico-legal implications. 152 HEPATITIS B PROPHYLAXIS POST LIVER TRANSPLANTATION WITH TENOFOVIR OR ENTECAVIR H. Elsiesy1 , F. Abaalkhail1 , A. Hashim1 , K. Atallah1 , M. Al Sebayel1 , W. Al Hamoudi2 , King Faisal Liver Group. 1 King Faisal Specialist Hospital & Research Center, 2 King Saud University Liver Disease Research Center, Riyadh, Saudi Arabia E-mail: [email protected] Background: The introduction of HBIG and lamivudine to prevent Hepatitis B (HBV) recurrence after liver transplantation (LT) has improved survival. However, both cost and disease recurrence primarily related to the development of lamivudine resistant strains remain a significant problem. Aim: To assess the safety and efficacy of entecavir and tenofovir in preventing HBV recurrence following liver transplantation. Method: Between January 1990 and December 2011 a total of 133 (106 males and 27 females) patients were transplanted at our center for HBV related cirrhosis. All patients received post transplant combination therapy with nucleos(t)ide analogue and anti-hepatitis B immunoglobulins. Breakthrough infection was defined as re-emergence of HBV-DNA or HBsAg while on treatment. Demographic, clinical and laboratory data including various viral markers were collected from all patients. Results: The majority of patients received lamivudine and/or adefovir in combination with HBIG. Ten and five patients received tenofovir and entecavir monotherapy, respectively. Post LT survival and HBV recurrence during the follow up period were 89% and 11%, respectively. The 15 patients (10 male & 5 females) who received the newer nucleos(t)ide analogues were followed for a mean of 32 (range=12–114) months after transplantation. Their age ranged between 34 and 64 while the MELD score ranged between 12–40. All 15 patients were positive for HbsAg and 13 were HBeAg negative. HBV DNA was negative in 9 patients at the time of transplantation and positive in 6 patients (2 with high viremia). All cases of recurrence occurred on lamivudine or adefovir monotherapy and were controlled with switching or adding another agent. None of the 15 patients treated with tenofovir or entacavir developed resistance and all patients had normal renal function during the follow-up period. none of the patients who had entecavir or tenofovir before transplant had recurrence after transplant. Conclusion: Tenofovir and Entecavir are safe and effective in prophylaxis of post liver transplant with high resistance barrier. No interaction with immunosuppression. No effect on renal function with tenofovir. It may provide an attractive alternative to long term HBIG use.
Journal of Hepatology 2013 vol. 58 | S63–S227
of whom 8 underwent transplantation more than five years after the diagnosis of cancer. Conclusions: Our data suggest that a cancer-free period of 5 or more years is associated with a very low risk of recurrence of cancer in this selected cohort of patients. Because of the increasing age of recipients and higher incidence of cancer in patients with cirrhosis, more patients with previously treated cancer are considered for liver transplantation. Careful risk-benefit assessment should be adopted prior to offering transplantation to a patient who had a cancer treated within the previous five years. As the recurrence of cancer was fatal in both cases, informed consent will play an important role in clinical management and also has medico-legal implications. 152 HEPATITIS B PROPHYLAXIS POST LIVER TRANSPLANTATION WITH TENOFOVIR OR ENTECAVIR H. Elsiesy1 , F. Abaalkhail1 , A. Hashim1 , K. Atallah1 , M. Al Sebayel1 , W. Al Hamoudi2 , King Faisal Liver Group. 1 King Faisal Specialist Hospital & Research Center, 2 King Saud University Liver Disease Research Center, Riyadh, Saudi Arabia E-mail: [email protected] Background: The introduction of HBIG and lamivudine to prevent Hepatitis B (HBV) recurrence after liver transplantation (LT) has improved survival. However, both cost and disease recurrence primarily related to the development of lamivudine resistant strains remain a significant problem. Aim: To assess the safety and efficacy of entecavir and tenofovir in preventing HBV recurrence following liver transplantation. Method: Between January 1990 and December 2011 a total of 133 (106 males and 27 females) patients were transplanted at our center for HBV related cirrhosis. All patients received post transplant combination therapy with nucleos(t)ide analogue and anti-hepatitis B immunoglobulins. Breakthrough infection was defined as re-emergence of HBV-DNA or HBsAg while on treatment. Demographic, clinical and laboratory data including various viral markers were collected from all patients. Results: The majority of patients received lamivudine and/or adefovir in combination with HBIG. Ten and five patients received tenofovir and entecavir monotherapy, respectively. Post LT survival and HBV recurrence during the follow up period were 89% and 11%, respectively. The 15 patients (10 male & 5 females) who received the newer nucleos(t)ide analogues were followed for a mean of 32 (range=12–114) months after transplantation. Their age ranged between 34 and 64 while the MELD score ranged between 12–40. All 15 patients were positive for HbsAg and 13 were HBeAg negative. HBV DNA was negative in 9 patients at the time of transplantation and positive in 6 patients (2 with high viremia). All cases of recurrence occurred on lamivudine or adefovir monotherapy and were controlled with switching or adding another agent. None of the 15 patients treated with tenofovir or entacavir developed resistance and all patients had normal renal function during the follow-up period. none of the patients who had entecavir or tenofovir before transplant had recurrence after transplant. Conclusion: Tenofovir and Entecavir are safe and effective in prophylaxis of post liver transplant with high resistance barrier. No interaction with immunosuppression. No effect on renal function with tenofovir. It may provide an attractive alternative to long term HBIG use.
Journal of Hepatology 2013 vol. 58 | S63–S227