RETRANSPLANTATION OF PATIENTS WITH SEVERE POSTTRANSPLANT HEPATITIS-B IN THE FIRST ALLOGRAFT

Background. The outcome of orthotopic liver transplantation (OLTX) in patients retransplanted for severe hepatitis B virus (HBV) in the firs t allograft has been poor due to high rates of HBV reinfection and eve n more aggressive disease in the second graft. Recent data suggest tha t hepatitis B immunoglobulin (HBIg) given after transplantation can be successful in delaying or preventing HBV reinfection in patients tran splanted for chronic hepatitis B cirrhosis. We report the successful r etransplantation of patients who developed recurrent or de novo hepati tis B after OLTX. Methods. Using similar HBIg regimens, two centers re transplanted seven patients after they developed recurrent or de novo hepatitis B in the first allograft. At retransplantation all seven pat ients were HBs antigen (Ag) positive; four patients were positive for HBeAg and HBV DNA by immunoblot assay, two patients were negative for HBeAg and HBV DNA, and one patient was positive for HBV DNA and negati ve for HBeAg. All patients were either HDV Ag or anti-HDV negative. On e patient was anti-HCV positive. All patients received HBIg infusions after retransplantation to maintain serum anti-HBs levels >500 IU/L in definitely. Results. After retransplantation, six of seven patients ar e alive (86%): all are without evidence of HBV recurrence with serum n egative for HBsAg, HBeAg, and HBV DNA by immunoblot assay. Liver biops ies are normal on routine studies with immunohistochemical stains for HBcAg and HBsAg also being negative. Mean follow-up of these six patie nts is 40.1 months (range 21-63 months). One patient (14%) developed H BV reinfection 7 months after his second transplant, in spite of maint aining target anti-HBs levels. He maintained stable liver function wit h minimal evidence of clinical hepatitis B, but died 8 months later fr om an unrelated stroke. Conclusions. We conclude that patients with re current or de novo hepatitis B after OLTX can be successfully retransp lanted using aggressive immunoprophylaxis to prevent REV reinfection. The failure of HBIg therapy in one patient underscores the need for ot her effective adjunctive anti-HBV modalities.