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Outcome of HBs antigen positive kidneys after renal transplantation
ELSEVIER
Outcome of HBs Antigen Positive Kidneys After Renal Transplantation C. Turc Baron, G.P. Pageaux, and G. Mourad RANSMISSION of hepatitis B virus (HBV) through kidney grafts is possible because HBV is present in circulating mononuclear cells and even in some renal cells.1 Dialysis patients are immunized against HBV by vaccination or previous infection, therefore we used HBs antigen (Ag) positive kidneys for renal transplantation.
T
hepatitis), and azathioprine was stopped; this resulted in improvement in transaminases. Circulating HBV D N A was positive before transplant; 15 months after stopping azathioprine, circulating and intrahepatic HBV-ADN were negative. DISCUSSION
PATIENTS AND METHODS
Between December 1991 and March 1996, eight renal transplant patients (four male, four female; mean age: 52.6 12 years; dialysis duration: 25 -+ 20 months) received HBs Ag positive grafts. Seven patients had high anti-HBs antibodies (>100 U/L): three after vaccination; four following HBV infection; and one was HBs Ag positive. Five of these patients were also positive for hepatitis virus (HCV+). Anti-HBs immunoglobulins (1000 units) were injected at time of transplant and six weeks later. Induction's immunosuppression included prednisolone, azathioprine, and ATG (thymoglobulin, Merieux Institute, Lyon, France). Cyclosporine (CyA) was introduced at day 8 and ATG stopped at day 10. Azathioprine was stopped at 6 months. Maintenance included CyA and prednisolone. Transaminases, bilirubin, HBs Ag, anti-HBs antibody (Ab), antiHBc Ab, and HBV DNA were regularly monitored. RESULTS
All patients are alive with a functioning graft. In the three vaccinated patients, HBs Ag and HBV D N A are negative 3 years after transplant; liver function and transaminases remained normal. In the four previously infected patients, HBs Ag and HBV D N A are also negative 0.5 to 4 years posttransplant; one of them had abnormal liver enzymes, but this patient was positive for HCV and H C V - R N A was positive. The HBs A g + patient developed cytolytic hepatitis after transplant. Liver biopsy also worsened (chronic active
0041-1345/97/$17.00 PII S004i- 1345(97)00443-0 2446
In our limited series of eight patients, transplantation of HBs Ag positive kidneys into patients with acquired antiHVBs antibodies (after vaccination or previous infection) is relatively safe. HBs Ag and HBV D N A remained negative in all of our patients, suggesting that there was no replication of the virus in the posttransplant period. However, a note of caution should be underlined because mutant viruses of HBV were described. These mutants may be transmitted to the recipient with anti-HBs Ab and result in acute hepatitis. 2'3 Detection of these mutant viruses is impossible with the usual serological methods, therefore a search for HBV D N A is needed. 4 REFERENCES 1. Samuel D, Bismuth H: Adv in Liver Transplant 22:271, 1993 2. Carman W, et al: Lancet 336:325, 1990 3. Barnaba V, Basalno F: J of Hepatology 14:391, 1992 4. Thiers V, et al: Lancet 2:1273, 1988
From the Departments of Nephrology and Hepatology, University Hospital, Montpellier, France. Address reprint requests to G. Mourad, Department of Nephrology, Hepital Lapeyronie, 371 Av Doyen G. Giraud, 34295 Montpellier Cedex 5, France.
© 1997 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
TransplantationProceedings, 29, 2446 (1997)
Outcome of HBs Antigen Positive Kidneys After Renal Transplantation C. Turc Baron, G.P. Pageaux, and G. Mourad RANSMISSION of hepatitis B virus (HBV) through kidney grafts is possible because HBV is present in circulating mononuclear cells and even in some renal cells.1 Dialysis patients are immunized against HBV by vaccination or previous infection, therefore we used HBs antigen (Ag) positive kidneys for renal transplantation.
T
hepatitis), and azathioprine was stopped; this resulted in improvement in transaminases. Circulating HBV D N A was positive before transplant; 15 months after stopping azathioprine, circulating and intrahepatic HBV-ADN were negative. DISCUSSION
PATIENTS AND METHODS
Between December 1991 and March 1996, eight renal transplant patients (four male, four female; mean age: 52.6 12 years; dialysis duration: 25 -+ 20 months) received HBs Ag positive grafts. Seven patients had high anti-HBs antibodies (>100 U/L): three after vaccination; four following HBV infection; and one was HBs Ag positive. Five of these patients were also positive for hepatitis virus (HCV+). Anti-HBs immunoglobulins (1000 units) were injected at time of transplant and six weeks later. Induction's immunosuppression included prednisolone, azathioprine, and ATG (thymoglobulin, Merieux Institute, Lyon, France). Cyclosporine (CyA) was introduced at day 8 and ATG stopped at day 10. Azathioprine was stopped at 6 months. Maintenance included CyA and prednisolone. Transaminases, bilirubin, HBs Ag, anti-HBs antibody (Ab), antiHBc Ab, and HBV DNA were regularly monitored. RESULTS
All patients are alive with a functioning graft. In the three vaccinated patients, HBs Ag and HBV D N A are negative 3 years after transplant; liver function and transaminases remained normal. In the four previously infected patients, HBs Ag and HBV D N A are also negative 0.5 to 4 years posttransplant; one of them had abnormal liver enzymes, but this patient was positive for HCV and H C V - R N A was positive. The HBs A g + patient developed cytolytic hepatitis after transplant. Liver biopsy also worsened (chronic active
0041-1345/97/$17.00 PII S004i- 1345(97)00443-0 2446
In our limited series of eight patients, transplantation of HBs Ag positive kidneys into patients with acquired antiHVBs antibodies (after vaccination or previous infection) is relatively safe. HBs Ag and HBV D N A remained negative in all of our patients, suggesting that there was no replication of the virus in the posttransplant period. However, a note of caution should be underlined because mutant viruses of HBV were described. These mutants may be transmitted to the recipient with anti-HBs Ab and result in acute hepatitis. 2'3 Detection of these mutant viruses is impossible with the usual serological methods, therefore a search for HBV D N A is needed. 4 REFERENCES 1. Samuel D, Bismuth H: Adv in Liver Transplant 22:271, 1993 2. Carman W, et al: Lancet 336:325, 1990 3. Barnaba V, Basalno F: J of Hepatology 14:391, 1992 4. Thiers V, et al: Lancet 2:1273, 1988
From the Departments of Nephrology and Hepatology, University Hospital, Montpellier, France. Address reprint requests to G. Mourad, Department of Nephrology, Hepital Lapeyronie, 371 Av Doyen G. Giraud, 34295 Montpellier Cedex 5, France.
© 1997 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
TransplantationProceedings, 29, 2446 (1997)