Liver transplantation and HBsAg-positive postnecrotic cirrhosis: adequate immunoprophylaxis and delta virus co-infection as the significant determinants of long-term prognosis

Background/Aims: The place of liver transplantation in hepatitis B viral (H BV)-related diseases remains controversial because of the high rate of rein fection. The aim of this: study was to define the determinants of long-term prognosis after transplantation. Methods: Fifty-eight patients were transplanted during the period February 1984-September 1996, Six patients: died during the early (<3 months) posttr ansplant period from causes unrelated to HBV infection. All 52 long-term (> 3 months) survivors were evaluated in relation to the mode of presentation, viral replication at time of transplantation, absence of hepatocellular ca ncer at time of transplantation and use of adequate immunoprophylaxis (IP). Adequate immunoprophylaxis, defined as maintenance of anti-HBs levels over 100 mUl/ml, was introduced in December 1989, Intention-to-treat IP analysi s compared patients transplanted before and after this date. The median fol low-up was 74 months (range 4 to 131), Forty-seven patients (90%) had a min imal follow-up of 3 years. Results: Five-year actuarial survival rates of 58 patients and of 52 long-t erm survivors were 72+/-6% and 80+/-6%, respectively. Univariate analysis s howed that delta co-infection (n=25) significantly improved survival (p<0.0 01) [96+/-4% vs 63+/-10% in HBV patients (n=27) at 5 years] as did absence of hepatocellular cancer (n=36) (p=0.020) [89+/-5% vs 61+/-12% in 16 non-ca ncer patients]. IP, However, significantly influenced 5-year survival in th e HBV-patient group (n= 17) (p=0.001) [85+/-10% vs 30+/-14% in 10 patients without IP). Multivariate analysis selected delta coinfection (p=0.002) and IP (p=0.01) as the significant determinants of prognosis independently inf luencing survival, Uni- and multivariate analyses showed that survival with out reinfection was significantly influenced by IP (p=0.002) [73+/-8% (n=31 ) versus 33+/-12% in 15 non-treated patients). Conclusions: Delta virus co-infection and immunoprophylaxis are the most im portant prognostic factors after transplantation for postnecrotic HBsAg-pos itive cirrhosis. Transplantation can be proposed as a therapeutic tool only if life-long adequate adjuvant therapy can be achieved. Under this conditi on good results can even be obtained if there is viral replication at the t ime of transplantation.