Combination low-dose hepatitis B immune globulin and lamivudine therapy provides effective prophylaxis against posttransplantation hepatitis B

Although antiviral prophylaxis with lamivudine monotherapy appears to reduc e post-liver transplantation recurrence of hepatitis B virus (HBV) infectio n, breakthrough infections occur in at least 20% of the patients because of the development of drug resistance. Combined lamivudine and intravenous he patitis B immune globulin (HBIG) therapy (10,000-IU doses) may reduce this risk, but its use is limited by cost (similar to US $45,000/yr) and availab ility, We report the experience at liver transplant centers in Australia an d New Zealand in which lamivudine has been used in combination with much lo wer doses of HBIG than used in conventional HBIG prophylaxis, Lamivudine, 1 00 mg/d, was administered to hepatitis B surface antigen (HBsAg)-positive c andidates on listing for transplantation and was continued posttransplantat ion. HBIG, 400 or 800 IU, was administered intramuscularly (IM) daily for 1 week from transplantation and monthly thereafter. Thirty-seven HBsAg-posit ive patients underwent transplantation using this protocol. Thirty-six of t hese patients were HBV DNA positive by polymerase chain reaction (PCR) or h ybridization assay. Thirty-four patients had chronic HBV, 2 patients had he patitis B and C, and 1 patient had hepatitis B, C, and D, Five patients die d within 1 month of transplantation and are not included in the analysis. M ean follow-up in the remaining 32 patients was 18.4 months (range, 5 to 45 months). Treatment was well tolerated, with no significant adverse events. Thirty-one of 32 patients were HBsAg negative, and all 32 patients were HBV DNA negative by PCR at latest follow-up, The cost of treatment was US $967 for lamivudine and between $2,290 and $4,480/yr for IM HBIG, Lamivudine an d low-dose HBIG treatment prevents posttransplantation recurrence of hepati tis B and is likely to be more cost-effective than high-dose HBIG regimens.