title: Liver Transplantation for Hepatitis B in Early Adulthood: Analysis of the United Network for Organ Sharing Database.
abstract: BACKGROUND
  Chronic hepatitis B virus (HBV) infection has a mild course in most children that may delay initiation of treatment even when indicated. Unfortunately, a small number of cases can progress rapidly to cirrhosis, which may require liver transplantation (LT) in early adulthood. The aim of this study was to assess the characteristics of HBV-positive young adults who received LT and to evaluate post-transplant outcomes including patient and graft survival and differences between pre- and post-implementation of Model for End-stage Liver Disease (MELD) prioritization.
  
  
  METHODS
  The United Network for Organ Sharing (UNOS) database review was conducted from 1987 to 2012, and a retrospective analysis was performed on all young adult patients (ages 18-35 years) who underwent LT in the United States with a primary diagnosis of HBV or were seropositive for HBV surface antigen at time of LT. Kaplan-Meier analysis was used to assess patient and graft survival in the pre-MELD and post-MELD eras. Factors associated with survival were identified through the use of Cox regression analysis.
  
  
  RESULTS
  A total of 522 HBV-infected subjects were included. Average age at time of transplant was 28.4 ± 5.2 years; 60.9% were male, 48.6% were white, the mean body mass index was 25 ± 5.5 kg/m2, diabetes was present in 3.9%, hepatocellular carcinoma (HCC) was present in 4.4%, and 10.4% were on dialysis prior to LT. Median follow-up after first LT was 48.2 months [12.5, 109]. During this time, 174 (33.3%) patients died with a mean age at the time of death of 31.6 ± 7.8 years, including 144 of 522 (28%) after the first LT, 26 of 74 (35%) after the second LT, and 4 of 12 (33%) after the third LT. The most common cause of death was graft failure (27.6%), followed by infection (16.6%). Overall, only 58% of patients were alive with their first LT at last follow-up. Kaplan-Meier analysis revealed worse patient and graft survival after re-transplantation in comparison to initial LT. Three hundred thirty subjects were transplanted in the pre-MELD era and 192 were transplanted in post-MELD era. Obesity, HCC, shorter ventilation use, shorter cold ischemia time, and non-white donor race were significantly more common in the post-MELD era (all with P < .05). Importantly, 5-year patient and graft survival rates were higher in the post-MELD era compared with the pre-MELD era.
  
  
  CONCLUSIONS
  LT in young adults for HBV has poor outcomes and can be associated with premature death. These findings should prompt more aggressive evaluation and treatment for HBV in young patients. Superior outcomes in the post-MELD era compared with the pre-MELD era may be attributed to pre-transplant factors, improved surgical technique, and better treatment options for HBV infection.
authors.affiliation: Department of Pediatric Gastroenterology, The Cleveland Clinic, Cleveland, Ohio.
authors.forename: G
authors.initials: G
authors.lastname: Rifai
authors.affiliation: Department of Digestive Disease, The Cleveland Clinic, Cleveland, Ohio.
authors.forename: A
authors.initials: A
authors.lastname: Anani
authors.affiliation: Department of Pediatric Gastroenterology, The Cleveland Clinic, Cleveland, Ohio.
authors.forename: I A
authors.initials: IA
authors.lastname: Hanouneh
authors.affiliation: Department of Pediatric Gastroenterology, The Cleveland Clinic, Cleveland, Ohio.
authors.forename: B
authors.initials: B
authors.lastname: Mohamad
authors.affiliation: Department of Digestive Disease, The Cleveland Clinic, Cleveland, Ohio.
authors.forename: A
authors.initials: A
authors.lastname: Matloob
authors.affiliation: Department of Digestive Disease, The Cleveland Clinic, Cleveland, Ohio.
authors.forename: R
authors.initials: R
authors.lastname: Lopez
authors.affiliation: Department of Digestive Disease, The Cleveland Clinic, Cleveland, Ohio.
authors.forename: N N
authors.initials: NN
authors.lastname: Zein
authors.affiliation: Department of Pediatric Gastroenterology, The Cleveland Clinic, Cleveland, Ohio; Department of Digestive Disease, The Cleveland Clinic, Cleveland, Ohio. Electronic address: alkhoun@ccf.org.
authors.forename: N
authors.initials: N
authors.lastname: Alkhouri
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D016208:Databases, Factual; D005260:Female; D006085:Graft Survival; D006509:Hepatitis B / Q000150:complications* / Q000821:virology; D006515:Hepatitis B virus; D006801:Humans; D053208:Kaplan-Meier Estimate; D008103:Liver Cirrhosis / Q000601:surgery* / Q000821:virology; D016031:Liver Transplantation / Q000401:mortality*; D008297:Male; D012086:Reoperation / Q000401:mortality; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult