New era of liver transplantation for hepatitis B: a 17-year single-center experience.
OBJECTIVE
To evaluate the variables affecting orthotopic liver transplantation (OLT) outcome for hepatitis B virus (HBV) in a large patient cohort over a 17-year period.


BACKGROUND
Historically, OLT for chronic HBV infection has been associated with aggressive reinfection and poor survival results. More recently, OLT outcome has been improved with the routine use of antiviral therapy with either hepatitis B immune globulin (HBIg) or lamivudine; however, HBV recurrence remains common. The authors studied the factors affecting HBV recurrence and outcome of transplantation, including the effects of combination viral prophylaxis with HBIg and lamivudine.


METHODS
A retrospective review of 166 OLT recipients for chronic HBV over a 17-year period at a single center was performed. Median follow-up was 29 months. HBV recurrence was defined by HBsAg seropositivity after OLT. HBIg monotherapy was used in 28 (17%) patients, lamivudine monotherapy in 20 (12%), and HBIg and lamivudine combination in 89 (54%); 29 (17%) did not receive any HBV prophylaxis. Hepatocellular carcinoma (HCC) was present in 43 patients (26%) and urgent United Network for Organ Sharing (UNOS) status was assigned to 27 patients (16%). Univariate and multivariate analyses were performed to identify factors that affected OLT outcome.


RESULTS
Overall 1-, 3-, and 5-year patient survival rates were 85.8%, 73.6%, and 71.8%, respectively. As expected, HBV recurrence-free survival rates were significantly lower than overall survival rates (76.4%, 58.7%, and 48.3%). When compared with a nontreated cohort, OLT recipients receiving combination viral prophylaxis with HBIg and lamivudine showed markedly reduced HBV recurrence rates and significantly improved 1- and 3-year recurrence-free survival rates. By univariate estimates, patient survival was reduced in the presence of HCC, in the Asian population, and urgent candidates by UNOS classification. Graft loss rates were significantly increased in urgent OLT candidates, Asians, patients with pretransplant positive DNA, and in the presence of HCC. Factors that were significant by univariate analysis or thought to be clinically relevant were subjected to multivariate analysis. By multivariate estimates, urgent UNOS or presence of HCC adversely affected patient and graft survival rates, whereas combination prophylactic therapy strongly predicted improved patient and graft survival rates as well as recurrence-free survival rates.


CONCLUSIONS
Orthotopic liver transplantation for HBV under combination viral prophylaxis results in survival rates equivalent to other indications. Pretransplant viral replication, UNOS status, and the presence of HCC are all sensitive markers for posttransplantation outcome. Viral prophylactic therapy has effectively reduced HBV recurrence and prolonged survival outcomes. The combination of HBIg and lamivudine is the prophylactic regimen of choice.
Anselmo
Dean M
DM
Department of Surgery, Dumont-UCLA Liver Transplant Center, UCLA School of Medicine, Los Angeles, California 90095-7054, USA.
Ghobrial
Rafik M
RM
Jung
Lee Chan
LC
Weaver
Michael
M
Cao
Carlos
C
Saab
Sammy
S
Kunder
Greg
G
Chen
Pauline W
PW
Farmer
Douglas G
DG
Yersiz
Hasan
H
Baquerizo
Angeles
A
Geevarghese
Sunil
S
Han
Steven H
SH
Goldstein
Leonard
L
Holt
Curtis D
CD
Gornbein
Jeffrey A
JA
Busuttil
Ronald W
RW
D000998:Antiviral Agents / Q000627:therapeutic use; D002423:Cause of Death; D015331:Cohort Studies; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006085:Graft Survival; D019694:Hepatitis B, Chronic / Q000601:surgery*; D006801:Humans; D007136:Immunoglobulins / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D019259:Lamivudine / Q000627:therapeutic use; D016031:Liver Transplantation / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012008:Recurrence; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome
D000998:Antiviral Agents; D007136:Immunoglobulins; D007166:Immunosuppressive Agents; D019259:Lamivudine; C045213:hepatitis B hyperimmune globulin