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Schwarz C, Morel A, Matignon M, Grimbert P, Rondeau E, Ouali N, François H, Mesnard L, Petit-Hoang C, Rafat C, Dahan K, Luque Y. Hepatitis B Virus Reactivation in Kidney Transplant Recipients Treated With Belatacept. Kidney Int Rep 2023; 8:1531-1541. [PMID: 37547512 PMCID: PMC10403656 DOI: 10.1016/j.ekir.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/30/2023] [Accepted: 05/08/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction Hepatitis B virus (HBV) reactivation in kidney transplant recipients has been reported in 3% to 9% of anti-HBc antibody (HBcAb)-positive HBs antigen (HBsAg)-negative patients. It has not been studied in patients receiving belatacept, a selective costimulation blocker. Methods We performed a retrospective study of all transplant recipients receiving belatacept in 2 kidney transplantation centers in France. Among HBcAb-positive patients, we analyzed HBV reactivation rate, outcomes, and risk factors. Results A total of 135 patients treated with belatacept were included: 32 were HBcAb-positive and 2 were HBsAg-positive. Seven patients reactivated HBV (21.9% of HBcAb-positive patients), including 5 HBsAg-negative patients (16.7% of HBcAb-positive HBsAg-negative patients). Reactivation occurred 54.8 (± 70.9) months after transplantation. One patient presented with severe hepatitis and 1 patient developed cirrhosis. There was no significant difference in survival between patients that reactivated HBV and patients that did not: 5-year patient survival of 100% (28.6; 100) and 83.4% (67.6; 100), respectively (P = 0.363); and 5-year graft survival of 100% (28.6; 100) and 79.8% (61.7; 100), respectively (P = 0.335). No factor, including HBsAb positivity and antiviral prophylaxis, was statistically associated with the risk of HBV reactivation. Conclusion HBV reactivation rate was high in patients treated with belatacept when compared with previous transplantation studies. HBV reactivation did not impact survival. Further studies are needed to confirm these results. A systematic antiviral prophylaxis for these patients should be considered and evaluated.
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Affiliation(s)
- Chloë Schwarz
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Antoine Morel
- Service de Néphrologie, Hôpital Henri Mondor, Assistance Publique–Hôpitaux de Paris, Créteil, France
| | - Marie Matignon
- Service de Néphrologie, Hôpital Henri Mondor, Assistance Publique–Hôpitaux de Paris, Créteil, France
| | - Philippe Grimbert
- Service de Néphrologie, Hôpital Henri Mondor, Assistance Publique–Hôpitaux de Paris, Créteil, France
| | - Eric Rondeau
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique–Hôpitaux de Paris, Paris, France
- Sorbonne Université, Unité CoRaKid, Inserm, UMR_S1155, Paris, France
| | - Nacera Ouali
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Hélène François
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique–Hôpitaux de Paris, Paris, France
- Sorbonne Université, Unité CoRaKid, Inserm, UMR_S1155, Paris, France
| | - Laurent Mesnard
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique–Hôpitaux de Paris, Paris, France
- Sorbonne Université, Unité CoRaKid, Inserm, UMR_S1155, Paris, France
| | - Camille Petit-Hoang
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Cédric Rafat
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Karine Dahan
- Néphrologie et Dialyses, Département de Néphrologie, Hôpital Tenon, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Yosu Luque
- Soins Intensifs Néphrologiques et Rein Aigu, Département de Néphrologie, Hôpital Tenon, Assistance Publique–Hôpitaux de Paris, Paris, France
- Sorbonne Université, Unité CoRaKid, Inserm, UMR_S1155, Paris, France
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Yin S, Zhang F, Wu J, Lin T, Wang X. Incidence, risk factors, and clinical outcomes of HBV reactivation in non-liver solid organ transplant recipients with resolved HBV infection: A systematic review and meta-analysis. PLoS Med 2023; 20:e1004196. [PMID: 36920988 PMCID: PMC10058170 DOI: 10.1371/journal.pmed.1004196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 03/29/2023] [Accepted: 02/09/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Current guidelines do not recommend routine antiviral prophylaxis to prevent hepatitis B virus (HBV) reactivation in non-liver solid organ transplant (SOT) recipients with resolved HBV infection, even in anti-hepatitis B surface antigen (anti-HBs)-negative recipients and those receiving intense immunosuppression. This systematic review and meta-analysis aimed to determine the incidence, risk factors, and clinical outcomes of HBV reactivation in non-liver SOT recipients. METHODS AND FINDINGS Three databases (PubMed, Embase, and Cochrane Library) were systematically searched up to December 31, 2022. Clinical studies reporting HBV reactivation in non-liver SOT recipients were included. Case reports, case series, and cohort studies with a sample size of less than 10 patients were excluded. Random-effects analysis was used for all meta-analyses. We included 2,913 non-liver SOT recipients with resolved HBV infection from 16 retrospective cohort studies in the analysis. The overall HBV reactivation rate was 2.5% (76/2,913; 95% confidence interval [95% CI 1.6%, 3.6%]; I2 = 55.0%). Higher rates of reactivation were observed in recipients with negative anti-HBs (34/421; 7.8%; 95% CI [5.2%, 10.9%]; I2 = 36.0%) by pooling 6 studies, experiencing acute rejection (13/266; 5.8%; 95% CI [2.3%, 14.5%]; I2 = 63.2%) by pooling 3 studies, receiving ABO blood type-incompatible transplantation (8/111; 7.0%; 95% CI [2.9%, 12.7%]; I2 = 0%) by pooling 3 studies, receiving rituximab (10/133; 7.3%; 95% CI [3.4%, 12.6%]; I2 = 0%) by pooling 3 studies, and receiving anti-thymocyte immunoglobulin (ATG, 25/504; 4.9%; 95% CI [2.5%, 8.1%]; I2 = 49.0%) by pooling 4 studies. Among recipients with post-transplant HBV reactivation, 11.0% (7/52; 95% CI [4.0%, 20.8%]; I2 = 0.3%) developed HBV-related hepatic failure, and 11.0% (7/52; 95% CI [4.0%, 20.8%]; I2 = 0.3%) had HBV-related death. Negative anti-HBs (crude odds ratio [OR] 5.05; 95% CI [2.83, 9.00]; p < 0.001; I2 = 0%), ABO blood type-incompatible transplantation (crude OR 2.62; 95% CI [1.05, 6.04]; p = 0.040; I2 = 0%), history of acute rejection (crude OR 2.37; 95% CI [1.13, 4.97]; p = 0.022; I2 = 0%), ATG use (crude OR 3.19; 95% CI [1.48, 6.87]; p = 0.003; I2 = 0%), and rituximab use (crude OR 3.16; 95% CI [1.24, 8.06]; p = 0.016; I2 = 0%) increased the risk of reactivation. Adjusted analyses reported similar results. Limitations include moderate heterogeneity in the meta-analyses and that most studies were conducted in kidney transplant recipients. CONCLUSIONS Non-liver SOT recipients with resolved HBV infection have a high risk of HBV-related hepatic failure and HBV-related death if HBV reactivation occurs. Potential risk factors for HBV reactivation include rituximab use, anti-thymocyte immunoglobulin use, anti-HBs negative status, acute rejection history, and ABO blood type-incompatible transplantation. Further research on monitoring and routine antiviral prophylaxis of non-liver SOT recipients at higher risk of HBV reactivation is required.
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Affiliation(s)
- Saifu Yin
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
- Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
| | - Fan Zhang
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
- Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
| | - Jiapei Wu
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
- Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
| | - Tao Lin
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
- Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
- * E-mail: (TL); (XW)
| | - Xianding Wang
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
- Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China
- * E-mail: (TL); (XW)
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3
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Yamada R, Morikawa K, Hotta K, Iwami D, Tanabe T, Murai S, Shinohara N, Yoshida S, Hosoda S, Kubo A, Tokuchi Y, Kitagataya T, Kimura M, Yamamoto K, Nakai M, Sho T, Suda G, Natsuizaka M, Ogawa K, Sakamoto N. Incidence of post-transplant hepatitis B virus reactivation with the use of kidneys from donors with resolved hepatitis B virus infection. J Viral Hepat 2022; 29:976-985. [PMID: 36031873 DOI: 10.1111/jvh.13740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 12/09/2022]
Abstract
Donors with resolved hepatitis B virus (HBV) infection may be a solution for the organ shortage for kidney transplantation (KT). The purpose of this study was to clarify the current state of HBV markers after KT from donors with resolved HBV infection to HBV naïve recipients and the rate of HBV reactivation in recipients with resolved HBV infection. Furthermore, we investigated HBV covalently closed circular DNA (cccDNA) in transplanted organs from donors with resolved HBV infection and the capability of HBV replication in kidney cell lines. We retrospectively analysed the HBV status of 340 consecutive donors and recipients who underwent KT in a single centre. We prospectively measured cccDNA by real-time polymerase chain reaction in kidney biopsy specimens of 32 donors with resolved HBV infection. HBV reactivation was found in three recipients with resolved HBV infection (4.8%, 3/63) after KT. We analysed 45 cases of transplantation from donors with resolved HBV infection to HBV-naive recipients. One case (2.2%, 1/45) became seropositive for hepatitis B core antibody (anti-HBc) and in another case (2.2%, 1/45), HBV-DNA was detected qualitatively in an HBV naive recipient with a donor with resolved HBV infection. In the latter case, cccDNA was measured in the donor kidney during KT. HBV replication was observed in kidney cell lines with HBV plasmid transfection. In conclusion, the risk of reactivation in anti-HBc-positive donors is relatively low. However, post-transplant HBV monitoring should be conducted in all at-risk cases.
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Affiliation(s)
- Ren Yamada
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Kenichi Morikawa
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Kiyohiko Hotta
- Department of Renal and Genitourinary Surgery, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Daiki Iwami
- Department of Renal and Genitourinary Surgery, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan.,Surgical Branch, Institute of Kidney Diseases, Jichi Medical University Hospital, Shimotsuke, Japan
| | - Tatsu Tanabe
- Department of Renal and Genitourinary Surgery, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Sachiyo Murai
- Department of Renal and Genitourinary Surgery, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Nobuo Shinohara
- Department of Renal and Genitourinary Surgery, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Sonoe Yoshida
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Shunichi Hosoda
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Akinori Kubo
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Yoshimasa Tokuchi
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Takashi Kitagataya
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Megumi Kimura
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Koji Yamamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Masato Nakai
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Takuya Sho
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Goki Suda
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Mitsuteru Natsuizaka
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Koji Ogawa
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Japan
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4
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KASL clinical practice guidelines for management of chronic hepatitis B. Clin Mol Hepatol 2022; 28:276-331. [PMID: 35430783 PMCID: PMC9013624 DOI: 10.3350/cmh.2022.0084] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 01/10/2023] Open
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5
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Bedi HK, Chahal D, Lowe CF, Ritchie G, Hussaini T, Marquez V, Yoshida EM. Occult Hepatitis B Reactivation after Liver Transplant: The Role of a Novel Mutation in the Surface Antigen. J Clin Transl Hepatol 2021; 9:136-138. [PMID: 33604265 PMCID: PMC7868691 DOI: 10.14218/jcth.2020.00090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/27/2020] [Accepted: 11/19/2020] [Indexed: 12/04/2022] Open
Abstract
Occult hepatitis B infection is characterized by loss of hepatitis B surface antigen (HBsAg) and persistence of low levels of hepatitis B virus (HBV) replication that may or may not be detectable in plasma/serum. We present a case of HBV reactivation in a male patient who underwent orthotopic liver transplant for hepatocellular carcinoma secondary to active hepatitis C (HCV) infection. Pre-transplant, he was HBsAg-negative and hepatitis B core antibody-positive, with an undetectable HBV viral load that was incidentally found to be positive at a very low HBV viral load on the day of transplant. Post-transplant, his HBsAg remained undetectable, with an undetectable HBV viral load, until eradication of his HCV infection with direct acting antiviral agents. After eradication of HCV, there was reactivation of HBV, with a high viral load and emergence of serum HBsAg. A deep sequencing genetic analysis of his HBV both pre- and post-transplant revealed the presence of a mutation in the "a" determinant of the HBV surface antigen. The role of HBV genotype 'a' determinant mutation in HBV reactivation post-transplant is unknown and needs further examination. Our experience suggests a possible role for antiviral prophylaxis in these patients or monitoring of HBV viral loads post-transplant.
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Affiliation(s)
- Harjot K. Bedi
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Daljeet Chahal
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Christopher F. Lowe
- Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Gordon Ritchie
- Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Trana Hussaini
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Vladimir Marquez
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Eric M. Yoshida
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
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6
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Japan Society of Hepatology Guidelines for the Management of Hepatitis B Virus Infection: 2019 update. Hepatol Res 2020; 50:892-923. [PMID: 32343469 DOI: 10.1111/hepr.13504] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/16/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023]
Abstract
The Drafting Committee for Hepatitis Management Guidelines established by the Japan Society of Hepatology published the first version of the Guidelines for the Management of Hepatitis B in 2013 (first English version in 2014), and has since been publishing updates to the Guidelines as new drugs become available, with the latest original Japanese version being Version 3.1. Herein, the Drafting Committee publishes the second English version that contains all the changes made since the first English version of the guidelines was published in 2014. This 2019 version covers: (i) the nucleos(t)ide analogs, tenofovir disoproxil fumarate and tenofovir alafenamide; (ii) updates to treatment recommendations and management of drug-resistant hepatitis B virus that reflect the new availability of these drugs; and (iii) new information about hepatitis B virus reactivation with each update. This latest update also contains information about treatment goals, indications for treatment and cessation of nucleos(t)ide analog therapy, most of which were covered by the first version.
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7
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Kim J, Chung SJ, Sinn DH, Lee KW, Park JB, Huh W, Lee JE, Jang HR, Kang W, Gwak GY, Paik YH, Choi MS, Lee JH, Koh KC, Paik SW. Hepatitis B reactivation after kidney transplantation in hepatitis B surface antigen-negative, core antibody-positive recipients. J Viral Hepat 2020; 27:739-746. [PMID: 32057171 DOI: 10.1111/jvh.13279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/18/2020] [Accepted: 01/27/2020] [Indexed: 12/11/2022]
Abstract
Nowadays, intensive immunosuppressive therapy including rituximab is commonly used prior to kidney transplantation (KT), raising concerns over hepatitis B virus (HBV) reactivation among hepatitis B surface antigen (HBsAg)-negative and anti-hepatitis B core (HBc)-positive KT recipients. Recent practice guidelines suggested watchful monitoring or antiviral prophylaxis for the first 6-12 months, the period of maximal immunosuppression. However, the actual risk for HBV reactivation, and whether short-term antiviral therapy in the early period is necessary, remains unclear. A total of 449 HBsAg-negative and anti-HBc-positive KT recipients were analysed for HBV reactivation. During a median follow-up of 6.7 (interquartile range: 4.2-9.4) years, HBV reactivation was observed in 9 patients (2.0%). The median time of HBV reactivation from KT was 2.8 years (range: 1.4-11.5 years), with cumulative incidence rates of 0%, 1% and 2% for 1, 3 and 5 years, respectively. There were no severe adverse outcomes, including liver transplantation or mortality related to HBV reactivation. The risk of HBV reactivation was not high, even in anti-HBs-negative patients (n = 60, 4% at 5 years), ABO mismatch (n = 92, 4% at 5 years), use of rituximab (n = 66, 3% at 5 years) or plasmapheresis (n = 17, 7% at 5 years), and acute rejection (n = 169, 3% at 5 years). In conclusion, the HBV reactivation risk was not high and the time of detection was not clustered in the early post-KT period. Our findings favour continued watchful monitoring over antiviral prophylaxis in the early period.
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Affiliation(s)
- Jihye Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se Jin Chung
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyo Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wooseong Huh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Eun Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Ryoun Jang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wonseok Kang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Geum-Youn Gwak
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong-Han Paik
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Seok Choi
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Hyeok Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Cheol Koh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Woon Paik
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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8
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Álvarez-López P, Riveiro-Barciela M, Oleas-Vega D, Flores-Cortes C, Román A, Perelló M, Berastegui C, Castells L, Esteban R, Buti M. Anti-HBc impacts on the risk of hepatitis B reactivation but not on survival of solid-organ transplant recipients. Medicine (Baltimore) 2020; 99:e19407. [PMID: 32118794 PMCID: PMC7478413 DOI: 10.1097/md.0000000000019407] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Immunosuppression can lead to hepatitis B virus (HBV) reactivation in hepatitis B core antigen antibodies (anti-HBc) positive patients, especially those undergoing chemotherapy, although there is limited data on solid organ recipients, especially lung transplantation. Our aim was to analyze the risk of HBV reactivation and the potential impact of anti-HBc-positive status (both donors and recipients) on prognosis in a lung, kidney, and liver transplantation cohort.Retrospective analysis including data from all transplants in adults (2011-2012) in a tertiary hospital, with prospective HBV serology study to assess the risk of reactivation and its possible impact on survival.In total, 392 transplant recipients were included (196 kidney, 113 lung, 83 liver). Pre-transplantation anti-HBc screening was more frequent in liver recipients (P < .001) and donors (P < .001) than in kidney or lung. Fifty-five (14%) recipients were anti-HBc-positive and were not undergoing antiviral prophylaxis. Three (5.4%) cases of HBV reactivation occurred: 2 in pre-transplant anti-HBc-positive recipients and 1 with prior unknown anti-HBc status. All were HBeAg+ with HBV deoxyribonucleic acid (DNA) >10E8 IU/mL and only mild fibrosis. Baseline recipient anti-HBc positive status was the only factor associated with HBV reactivation. No reactivation cases occurred in lung or kidney recipients of anti-HBc positive grafts. Survival was lower in lung transplants, especially in human immunodeficiency virus-infected patients and those with prior immunosuppression.Anti-HBc positive status is a risk factor for HBV reactivation in solid organ recipients. Anti-HBc testing is highly recommended in solid-organ transplant recipients in order to identify those anti-HBc positive and therefore candidates for periodical hepatitis B surface antigen (HBsAg) and HBV DNA screening after transplant.
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Affiliation(s)
| | - Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid
| | | | | | - Antonio Román
- Pulmonology Service, Lung Transplant Program Vall d’Hebron Hospital, Barcelona, Spain
| | | | - Cristina Berastegui
- Pulmonology Service, Lung Transplant Program Vall d’Hebron Hospital, Barcelona, Spain
| | - Lluis Castells
- Liver Unit, Internal Medicine Department
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid
| | - Rafael Esteban
- Liver Unit, Internal Medicine Department
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid
| | - María Buti
- Liver Unit, Internal Medicine Department
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid
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9
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MORETTO F, CATHERINE FX, ESTEVE C, BLOT M, PIROTH L. Isolated Anti-HBc: Significance and Management. J Clin Med 2020; 9:E202. [PMID: 31940817 PMCID: PMC7019847 DOI: 10.3390/jcm9010202] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 12/11/2022] Open
Abstract
Hepatitis B virus (HBV) infection is prevalent worldwide and is associated with dramatic levels of morbidity and mortality. Isolated anti-HBc (IAHBc) is a particular serological pattern that is commonly found in immunocompromised patients. There is ongoing debate regarding the management of patients with IAHBc. Herein, we summarize the current guidelines and the newest evidence. The frequency of IAHBc is variable, with a higher prevalence in some populations, such as persons living with HIV and others immunocompromised patients. The risk of HBV reactivation depends on host factors (including immunosuppression) and viral factors. It is now well established that immunocompromised patients can be classified into three groups for risk according to the type of immunosuppression and/or treatment. In patients at high risk, HBV therapy has to be considered systematically. In patients at moderate risk, the decision is based on the level of HBV DNA (preemptive treatment or monitoring and vaccination). In patients with low risk, HBV vaccination is another possible approach, although further studies are needed to assess the type of preemptive strategy.
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Affiliation(s)
- Florian MORETTO
- Infectious Diseases Department, Dijon University Hospital, 21079 Dijon, France; (F.M.); (F.-X.C.); (C.E.); (M.B.)
| | - François-Xavier CATHERINE
- Infectious Diseases Department, Dijon University Hospital, 21079 Dijon, France; (F.M.); (F.-X.C.); (C.E.); (M.B.)
| | - Clémentine ESTEVE
- Infectious Diseases Department, Dijon University Hospital, 21079 Dijon, France; (F.M.); (F.-X.C.); (C.E.); (M.B.)
| | - Mathieu BLOT
- Infectious Diseases Department, Dijon University Hospital, 21079 Dijon, France; (F.M.); (F.-X.C.); (C.E.); (M.B.)
- INSERM CIC 1432, Module Plurithématique, University of Burgundy, 21079 Dijon, France
| | - Lionel PIROTH
- Infectious Diseases Department, Dijon University Hospital, 21079 Dijon, France; (F.M.); (F.-X.C.); (C.E.); (M.B.)
- INSERM CIC 1432, Module Plurithématique, University of Burgundy, 21079 Dijon, France
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10
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Sasadeusz J, Grigg A, Hughes PD, Lee Lim S, Lucas M, McColl G, McLachlan SA, Peters MG, Shackel N, Slavin M, Sundararajan V, Thompson A, Doyle J, Rickard J, De Cruz P, Gish RG, Visvanathan K. Screening and Prophylaxis to Prevent Hepatitis B Reactivation: Transplant Recipients. Clin Liver Dis 2019; 23:493-509. [PMID: 31266623 DOI: 10.1016/j.cld.2019.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Organ transplantation is a lifesaving procedure for many patients. To prevent rejection or graft-versus-host disease, recipients require long-term immunosuppression. In patients who have ever been exposed to hepatitis B, it is possible for reactivation to occur; this includes patients who are anti-hepatitis B core antibody-positive only or both anti-hepatitis B core antibody-positive and hepatitis B surface antibody-positive. The susceptibility to this varies with the nature of the transplant. Hepatitis B can be transmitted from donor to recipient. It is important to assess the hepatitis B status and formulate a strategy to prevent transmission and prevent reactivation.
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Affiliation(s)
- Joe Sasadeusz
- Peter Doherty Institute for Infection and Immunity, Elizabeth Street, Melbourne, Victoria 3000, Australia; University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia.
| | - Andrew Grigg
- Olivia Newton John Cancer Research Institute, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia
| | - Peter D Hughes
- University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia; Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Seng Lee Lim
- National University of Singapore, 21 Lower Kent Ridge Road, Singapore 119077, Singapore
| | - Michaela Lucas
- University of Western Australia, 35 Stirling Highway, Crawley, Western Australia 6009, Australia
| | - Geoff McColl
- University of Queensland Oral Health Centre, 288 Herston Road, Queensland 4006, Australia
| | - Sue Anne McLachlan
- St Vincent's Hospital, 41 Victoria Street, Fitzroy, Victoria 3065, Australia
| | - Marion G Peters
- University of California, San Francisco, S357 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Nicholas Shackel
- Ingham Institute, 1 Campbell Street, Liverpool, Sydney, New South Wales 2170, Australia
| | - Monica Slavin
- Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia; Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Vijaya Sundararajan
- University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia; St Vincent's Hospital, 41 Victoria Street, Fitzroy, Victoria 3065, Australia; Department of Public Health, La Trobe University, Plenty Road, Bundoora, Victoria 3086, Australia
| | - Alexander Thompson
- University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia; St Vincent's Hospital, 41 Victoria Street, Fitzroy, Victoria 3065, Australia
| | - Joseph Doyle
- The Alfred and Monash University, 85 Commercial Road, Melbourne, Victoria 3004, Australia; Burnet Institute, 85 Commercial Road, Melbourne, Victoria 3004, Australia
| | - James Rickard
- Olivia Newton John Cancer Research Institute, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia
| | - Peter De Cruz
- University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia
| | - Robert G Gish
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Kumar Visvanathan
- University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia; St Vincent's Hospital, 41 Victoria Street, Fitzroy, Victoria 3065, Australia
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11
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Presence of Hepatitis B Surface Antibody in Addition to Hepatitis B Core Antibody Confers Protection Against Hepatitis B Virus Infection in Hepatitis B Surface Antigen-negative Patients Undergoing Kidney Transplantation. Transplantation 2019; 102:1717-1723. [PMID: 29621059 DOI: 10.1097/tp.0000000000002173] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The American Gastroenterological Association and European Association for the Study of the Liver recommend that hepatitis B surface antigen (HBsAg)-negative and hepatitis B core antibody (anti-HBc)-positive patients who receive immunosuppression should be monitored for hepatitis B virus (HBV) infection regardless of hepatitis B surface antibody (anti-HBs) status. However, anti-HBs may provide protection against infection. To investigate whether the presence of anti-HBs in addition to anti-HBc confers protection, we classified HBsAg(-) kidney transplantation (KT) patients into 4 groups according to anti-HBc and anti-HBs status, and compared the HBV infection rate between the anti-HBc(+)anti-HBs(+) group and the other 3 groups. METHODS In this single-center retrospective study, we classified 1959 patients into 4 groups: anti-HBc(-)anti-HBs(-) (n = 356), anti-HBc(-)anti-HBs(+) (n = 652), anti-HBc(+)anti-HBs(-) (n = 142), and anti-HBc(+)anti-HBs(+) (n = 809). RESULTS Hepatitis B virus infection was noted in 31 (1.6%) patients after KT. There was a significant difference in HBV infection rate between anti-HBc(+)anti-HBs(+) (1.2%) and anti-HBc(+)anti-HBs(-) (5.6%) (P < 0.001), but not between anti-HBc(+)anti-HBs(+) and anti-HBc(-)anti-HBs(-) (1.1%) or anti-HBc(-)anti-HBs(+) (1.4%). There was a significant difference in HBV infection rate according to anti-HBs titer, but no difference according to the donor viral profile. Hepatic failure occurred in 1 anti-HBc(+)anti-HBs(-) patient and 1 anti-HBc(+)anti-HBs(+) patient, both of whom died. Hepatocellular carcinoma was noted in 4 anti-HBc(-) patients, but not in anti-HBc(+) patients. CONCLUSIONS The presence of anti-HBs confers protection against HBV infection. We recommend monitoring for HBV infection after KT in HBsAg(-) anti-HBc(+) anti-HBs(-) patients, but not in HBsAg(-) anti-HBc(+) anti-HBs(+) patients.
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12
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Muche M, Berg T, Rimpler S, Staedtler A, Böhm S, Nickel P, Baid-Agrawal S. Low prevalence of occult hepatitis B virus infection in chronic haemodialysis and kidney transplant patients. Liver Int 2019; 39:263-270. [PMID: 30171739 DOI: 10.1111/liv.13951] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/09/2018] [Accepted: 08/12/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Occult hepatitis B virus infection (OBI) is defined as the presence of hepatitis B virus (HBV) DNA in serum and/or liver in HBsAg-negative patients. We investigated the prevalence of OBI in large chronic haemodialysis (CHD) and kidney transplant recipients (KTxR) cohorts, including determination of HBV DNA in peripheral blood mononuclear cells (PBMCs). METHODS HBV DNA was determined in both serum and PBMCs in 417 CHD patients, 417 KTxR, 20 HBsAg-positive non-CHD non-KTx patients (positive controls) and 40 HBsAg-negative healthy subjects (negative controls). RESULTS Chronic haemodialysis group: two of 376 patients were HBsAg-positive. The 374 HBsAg-negative patients tested negative for HBV DNA in both serum and PBMCs. KTxR group: 14 of 417 patients were HBsAg-positive. One of 403 HBsAg-negative patients tested positive for HBV DNA in serum but not in PBMCs. Positive controls: six of 20 patients were under antiviral therapy and had negative HBV DNA in both serum and PBMCs. In 11 of 14 remaining patients, HBV DNA was detected in serum and in both serum and PBMCs in 3 patients. Negative controls: All 34 patients were anti-HBc-negative and HBV DNA-negative in both serum and PBMCs. In the long term, the only case of anti-HBc-negative OBI lost anti-HBs 5 years after inclusion in the study and showed HBV reactivation with HBsAg re-seroconversion. CONCLUSIONS We found nil prevalence of OBI in CHD patients and a very low prevalence (<1%) in KTxR suggesting that routine screening for HBV DNA is not required in CHD population in our region. However, in KTxR, pretransplant screening with HBV DNA should be considered. Testing for HBV DNA in PBMCs does not seem to be of additional value.
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Affiliation(s)
- Marion Muche
- Department of Gastroenterology and Hepatology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Thomas Berg
- Section Hepatology, Clinic for Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Sunda Rimpler
- Department of Nephrology and Medical Intensive Care, Charite Universitaetsmedizin Berlin, Berlin, Germany
| | - Adrienne Staedtler
- Department of Nephrology and Medical Intensive Care, Charite Universitaetsmedizin Berlin, Berlin, Germany
| | - Stefan Böhm
- Max von Pettenkofer-Institute for Hygiene and Clinical Microbiology, Ludwig-Maximilians-Universität, Munich, Germany
| | - Peter Nickel
- Department of Nephrology and Medical Intensive Care, Charite Universitaetsmedizin Berlin, Berlin, Germany
| | - Seema Baid-Agrawal
- Department of Nephrology and Medical Intensive Care, Charite Universitaetsmedizin Berlin, Berlin, Germany.,Department of Nephrology and Transplant Center, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
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13
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Chancharoenthana W, Leelahavanichkul A, Udomkarnjananun S, Wattanatorn S, Avihingsanon Y, Praditpornsilpa K, Tungsanga K, Eiam-Ong S, Townamchai N. Durability of Antibody Response Against the Hepatitis B Virus in Kidney Transplant Recipients: A Proposed Immunization Guideline From a 3-Year Follow-up Clinical Study. Open Forum Infect Dis 2018; 6:ofy342. [PMID: 30697573 PMCID: PMC6330517 DOI: 10.1093/ofid/ofy342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 12/14/2018] [Indexed: 12/17/2022] Open
Abstract
Background Despite the importance of hepatitis B virus (HBV) immunization in kidney transplantation (KT), data are lacking on fluctuations in hepatitis B surface antibody (anti-HBsAb) levels and optimal levels for KT recipients. Methods The study consisted of anti-HBsAb-positive recipients aged 18–70 years at the time of the KT. Recipients with anti-HBsAb <100 IU/L received a single booster HBV vaccination, and anti-HBsAb was measured at baseline and 3, 6, 12, 18, and 24 months post-KT. Anti-HBsAb, quantitative HBV deoxyribonucleic acid testing (12 and 24 months post-KT), and hepatitis B core-related antigen (24 months post-KT) were evaluated in recipients with anti-HBsAb >100 IU/L who received a hepatitis B surface antigen positive renal allograft. Results Seventy-six of 257 (29.6%) KT recipients with anti-HBsAb <100 IU/L at the time of enrollment received a single booster of HBV vaccination. Anti-HBsAb levels increased (≥100 IU/L) 1 and 3 months post-booster dose in 86% and 93% of cases, respectively. Anti-HBsAb levels were ≥100 IU/L in 95% of these recipients 6 months post-booster dose. Among 181 (70%) recipients with anti-HBsAb ≥100 IU/L without a booster dose, anti-HBsAb gradually decreased after the KT from 588 IU/L at baseline to 440 and 382 IU/L 3 and 6 months post-KT, respectively (P < .01). Conclusions To ensure optimal immunity against HBV, KT recipients should first be stratified according to their risk of HBV reactivation. Kidney transplantation recipients of renal allografts from HBV nonviremic or viremic donors should be reimmunized when their anti-HBsAb titers are <250 IU/L. A cutoff level of 100 IU/L is recommended in other cases.
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Affiliation(s)
- Wiwat Chancharoenthana
- Division of Nephrology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellent Center of Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Asada Leelahavanichkul
- Immunology Unit, Department of Microbiology, Chulalongkorn University, Bangkok, Thailand
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellent Center of Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Salin Wattanatorn
- Division of Nephrology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellent Center of Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Yingyos Avihingsanon
- Division of Nephrology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellent Center of Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | | | - Kriang Tungsanga
- Division of Nephrology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Natavudh Townamchai
- Division of Nephrology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellent Center of Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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14
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Meng C, Belino C, Pereira L, Pinho A, Sampaio S, Tavares I, Bustorff M, Sarmento A, Pestana M. Reactivation of Hepatitis B virus in kidney transplant recipients with previous clinically resolved infection: A single-center experience. Nefrologia 2018; 38:545-550. [PMID: 29709320 DOI: 10.1016/j.nefro.2018.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 01/11/2018] [Accepted: 02/08/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Hepatitis B virus (HBV) reactivation in kidney transplant recipients (KTR) involves important morbidity and mortality. Despite being more common in patients who are HBsAg-positive, it may occur in patients with clinically resolved infection (HBsAg-negative and anti-HBc-positive), in whom the presence of the protective anti-HB antibody is thought to decrease the risk of reactivation. Data regarding reactivation rates in this population are scarce. OBJECTIVE To retrospectively evaluate the risk of HBV reactivation in KTR with previously resolved infection. MATERIAL AND METHODS Retrospective cohort study including patients who underwent a kidney transplant between January 1994 and December 2014 with resolved HBV infection at the time of transplantation (anti-HBc seropositivity without detectable HBsAg, with or without anti-HB-positive antibodies and normal liver enzymes). RESULTS Out of 966 patients, 95 patients with evidence of resolved HBV infection were analyzed, of which 86 had a titer of anti-HBs >10mIU/ml. Mean follow-up time was 93 months; 12 patients had lost anti-HBs. Two patients showed evidence of reactivation. Risk factors associated with loss of anti-HBs were elderly age (>60) and occurrence of acute graft rejection (p<0.05). CONCLUSION The risk of HBV reactivation in KTR with previously resolved infection is not negligible at 2%. Elderly age and acute rejection were associated with loss of anti-HBs, and these patients may benefit from closer monitoring of HBV DNA levels. Routine serology and/or HBV viral load monitoring in HBsAg-negative, anti-HBc-positive patients is recommended and should be emphasized in these patients.
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Affiliation(s)
- Catarina Meng
- Nephrology Department, Centro Hospitalar de São João, Porto, Portugal; Nephrology and Infecciology Group, INEB/I3S, Porto, Portugal.
| | - Carolina Belino
- Nephrology Department, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
| | - Luciano Pereira
- Nephrology Department, Centro Hospitalar de São João, Porto, Portugal; Nephrology and Infecciology Group, INEB/I3S, Porto, Portugal
| | - Ana Pinho
- Nephrology Department, Centro Hospitalar de São João, Porto, Portugal; Nephrology and Infecciology Group, INEB/I3S, Porto, Portugal
| | - Susana Sampaio
- Nephrology Department, Centro Hospitalar de São João, Porto, Portugal; Nephrology and Infecciology Group, INEB/I3S, Porto, Portugal
| | - Isabel Tavares
- Nephrology Department, Centro Hospitalar de São João, Porto, Portugal; Nephrology and Infecciology Group, INEB/I3S, Porto, Portugal
| | - Manuela Bustorff
- Nephrology Department, Centro Hospitalar de São João, Porto, Portugal; Nephrology and Infecciology Group, INEB/I3S, Porto, Portugal
| | - António Sarmento
- Nephrology and Infecciology Group, INEB/I3S, Porto, Portugal; Infectious Diseases Department, Centro Hospitalar de São João, Porto, Portugal; Faculty of Medicine of University of Porto, Porto, Portugal
| | - Manuel Pestana
- Nephrology Department, Centro Hospitalar de São João, Porto, Portugal; Nephrology and Infecciology Group, INEB/I3S, Porto, Portugal; Faculty of Medicine of University of Porto, Porto, Portugal
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15
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Choi J, Lim YS. Characteristics, Prevention, and Management of Hepatitis B Virus (HBV) Reactivation in HBV-Infected Patients Who Require Immunosuppressive Therapy. J Infect Dis 2017; 216:S778-S784. [PMID: 29156044 DOI: 10.1093/infdis/jix178] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hepatitis B virus (HBV) reactivation becomes a challenging issue with increasing use of immunosuppressive agents and cytotoxic chemotherapy for varied medical conditions, including cancer. The spectrum of HBV reactivation in the setting of immunosuppression may vary from asymptomatic reactivation to liver failure leading to death. HBV reactivation can hamper the course of planned therapies and diminish the effects of therapies; thus, it adversely affects the prognosis of the original disease and the survival of the patients. There is mounting evidence that HBV reactivation can be prevented and managed if patients are screened to determine their risk for HBV reactivation and are treated prophylactically before therapy with immunosuppressive agents or cytotoxic chemotherapy is initiated. In this article, we review the diagnostic criteria and clinical outcomes of HBV reactivation, discuss how immunosuppressive therapy may influence the risk of HBV reactivation, and outline strategies to prevent HBV reactivation.
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Affiliation(s)
- Jonggi Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Suk Lim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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16
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Vitrone M, Iossa D, Rinaldi L, Pafundi PC, Molaro R, Parrella A, Andini R, Ragone E, Maiello C, Zampino R, Durante-Mangoni E. Hepatitis B virus reactivation after heart transplant: Incidence and clinical impact. J Clin Virol 2017; 96:54-59. [PMID: 28964958 DOI: 10.1016/j.jcv.2017.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 09/21/2017] [Accepted: 09/22/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Occult hepatitis B infection consists of persistence of HBV genomes in hepatocytes,absence of serum HBsAg, low/undetectable serum HBVDNA. Reactivation of HBV infection may occur during immunosuppression, but few data are available in heart transplant. OBJECTIVES We followed-up heart recipients with or without markers of previous HBV infection,evaluating prevalence of HBV markers, incidence of HBV reactivation and its virological and clinical features. STUDY DESIGN Heart failure patients listed for heart transplant (2007-2013) were screened for current or past HBV infection. Transplanted patients with past HBV infection (anti-HBc+/±anti-HBs+/HBVDNA-) were followed up as cases, and an equal number of HBV negative patients as controls. Virological reactivation was detected by standard real-time and home-made highly sensitive PCR (surface/core HBVDNA regions). Clinical status and progression were assessed by liver histology, ultrasound or elastography. RESULTS 67 patients underwent heart transplant, including 4 (5.9%) HBsAg+ subjects. Cases were 11/67 (16.4%). During a median follow-up of 30 months, only one of these 11 patients presented viral reactivation (HBVDNA 209IU/mL) at month 22, and started antiviral treatment. Four other recipients showed virological events of uncertain significance (sensitive PCR-only intermittently positive). Clinical signs of liver disease were observed in only one case at the last follow-up. A nonsignificant difference in survival was observed between cases and all other heart recipients without prior HBV contact (death rate 5/11 vs 15/52, respectively; p=0.097). CONCLUSIONS HBV genotypic reactivation in HBsAg-/anti-HBc+/HBVDNA- heart recipients is uncommon. Virological events of uncertain significance occur more frequently; their clinical impact seems to be negligible.
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Affiliation(s)
- Martina Vitrone
- Internal Medicine, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Piazzale Ettore Ruggieri snc, 80131, Naples, Italy.
| | - Domenico Iossa
- Internal Medicine, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Piazzale Ettore Ruggieri snc, 80131, Naples, Italy
| | - Luca Rinaldi
- Internal Medicine, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Piazzale Ettore Ruggieri snc, 80131, Naples, Italy
| | - Pia Clara Pafundi
- Internal Medicine, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Piazzale Ettore Ruggieri snc, 80131, Naples, Italy
| | - Rosa Molaro
- Internal Medicine, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Piazzale Ettore Ruggieri snc, 80131, Naples, Italy
| | - Antonio Parrella
- Internal Medicine, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Piazzale Ettore Ruggieri snc, 80131, Naples, Italy
| | - Roberto Andini
- Internal Medicine, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Piazzale Ettore Ruggieri snc, 80131, Naples, Italy
| | - Enrico Ragone
- Units of Infectious & Transplant Medicine, Monaldi Hospital, Piazzale Ettore Ruggieri snc, 80131, Naples, Italy
| | - Ciro Maiello
- Cardiac Surgery, AORN dei Colli, Monaldi Hospital, Piazzale Ettore Ruggieri snc, 80131, Naples, Italy
| | - Rosa Zampino
- Internal Medicine, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Piazzale Ettore Ruggieri snc, 80131, Naples, Italy; Units of Infectious & Transplant Medicine, Monaldi Hospital, Piazzale Ettore Ruggieri snc, 80131, Naples, Italy
| | - Emanuele Durante-Mangoni
- Internal Medicine, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Piazzale Ettore Ruggieri snc, 80131, Naples, Italy; Units of Infectious & Transplant Medicine, Monaldi Hospital, Piazzale Ettore Ruggieri snc, 80131, Naples, Italy
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17
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Fukuda W, Hanyu T, Katayama M, Mizuki S, Okada A, Miyata M, Handa Y, Hayashi M, Koyama Y, Arii K, Kitaori T, Hagiyama H, Urushidani Y, Yamasaki T, Ikeno Y, Suzuki T, Omoto A, Sugitani T, Morita S, Inokuma S. Incidence of hepatitis B virus reactivation in patients with resolved infection on immunosuppressive therapy for rheumatic disease: a multicentre, prospective, observational study in Japan. Ann Rheum Dis 2016; 76:1051-1056. [PMID: 27934678 DOI: 10.1136/annrheumdis-2016-209973] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 11/07/2016] [Accepted: 11/08/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although the reactivation of hepatitis B virus (HBV) is recognised as a serious complication in patients with rheumatic disease (RD) receiving immunosuppressive drugs (ISDs), the incidence and risk factors for reactivation remain controversial. OBJECTIVES To investigate the incidence and risk factors for HBV reactivation in patients with RD. METHODS We performed a multicentre, observational, prospective study over 2 years in patients with resolved HBV infection. Patients with RD treated with a dose of ≥5 mg/day prednisolone and/or synthetic or biological ISDs with negative HB virus surface antigen and positive anti-HB virus surface antibody (HBsAb) and/or anti-HB virus core antibody (HBcAb) were enrolled. Quantitative HBV DNA results and related data were regularly recorded. RESULTS Among 1042 patients, including 959 with rheumatoid arthritis, HBV DNA was detected in 35 (1.93/100 person-years), with >2.1 log copies/mL observed in 10 patients (0.55/100 person-years). None of the reactivated patients, including seven treated with a nucleic acid analogue, showed overt hepatitis. Low HBsAb titres and advanced age seemed to be risk factors for HBV reactivation; however, reactivation was observed in three patients with positive HBsAb and negative HBcAb test results. The risk of reactivation was lower with methotrexate but higher with prednisolone among the different types of ISDs. The intervals from the start of ISD to reactivation were relatively long (3-182 months; median, 66 months). CONCLUSIONS The incidence of HBV reactivation with ISD use was 1.93/100 person-years in patients with RD with resolved HBV infection. No overt hepatitis was observed in the reactivated patients.
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Affiliation(s)
- Wataru Fukuda
- Center for Rheumatic Disease, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Tadamasa Hanyu
- Department of Rheumatology, Nagaoka Red Cross Hospital, Niigata, Japan
| | - Masaki Katayama
- Department of Rheumatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Shinichi Mizuki
- Department of Rheumatology, Matsuyama Red Cross Hospital, Ehime, Japan
| | - Akitomo Okada
- Department of Rheumatology, Japanese Red Cross Nagasaki Genbaku Hospital, Nagasaki, Japan
| | - Masayuki Miyata
- Department of Internal Medicine, Japanese Red Cross Fukushima Hospital, Fukushima, Japan
| | - Yuichi Handa
- Department of Rheumatology, Saitama Red Cross Hospital, Saitama, Japan
| | - Masatoshi Hayashi
- Department of Orthopedic Surgery and Rheumatology, Nagano Red Cross Hospital, Nagano, Japan
| | - Yoshinobu Koyama
- Department of Rheumatology, Japanese Red Cross Okayama Hospital, Okayama, Japan
| | - Kaoru Arii
- Department of Internal Medicine, Japanese Red Cross Kochi Hospital, Kochi, Japan
| | - Toshiyuki Kitaori
- Department of Orthopedics, Japanese Red Cross Fukui Hospital, Fukui, Japan
| | | | | | - Takahito Yamasaki
- Department of Rehabilitation, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Yoshihiko Ikeno
- Department of Rheumatology, Nasu Red Cross Hospital, Tochigi, Japan
| | - Tsuyoshi Suzuki
- Division of Allergy and Rheumatology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Atsushi Omoto
- Center for Rheumatic Disease, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Toshifumi Sugitani
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shigeko Inokuma
- Department of Allergy and Rheumatology, Chiba Central Medical Center, Chiba, Japan
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18
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Comparison of Clinical Outcomes in Hepatitis B Virus–Positive and –Negative Renal Transplant Recipients. Int Surg 2016. [DOI: 10.9738/intsurg-d-15-00144.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Our aim was to compare the short- and long-term clinical outcomes of hepatitis B surface antigen–positive (HbsAg+) renal transplant recipients with HbsAg− recipients. A total of 204 patients who underwent renal transplantation in our center between 2001 and 2014 were included in the study. The patients were divided into 2 groups. Group 1 was the HbsAg− group (n = 136), and group 2 was the HbsAg+ group (n = 68). There was no significant difference between the groups in terms of lymphocyte crossmatches, numbers of mismatches, immunosuppressive treatment protocols, and induction treatments. In the HbsAg+ group, 51 patients were hepatitis B virus DNA+, 64 patients were HbeAg−, and 4 patients were HbeAg+. A total of 57 patients (83.8%) were treated with lamivudine, 4 patients (5.9%) with entecavir, and 7 patients (10.3%) with tenofovir for hepatitis B infection. Graft and patient survival rates, graft functions, acute hepatitis rates, acute rejection rates, and other clinical outcomes of the groups were compared. Demographic data and immunologic risk profiles of the groups were similar. Acute rejection rates, graft survival rates, and patient survival rates were similar. Acute hepatitis rates, glomerular filtration rates on the last controls, and delayed graft function rates were higher in group 2, whereas chronic allograft dysfunction and new-onset diabetes mellitus after transplantation rates were similar between the groups. Our study revealed that graft and patient survival, and acute rejection rates were similar between HbsAg+ and HbsAg− recipients, whereas acute hepatitis rate was higher in HbsAg+ recipients.
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Pattullo V. Prevention of Hepatitis B reactivation in the setting of immunosuppression. Clin Mol Hepatol 2016; 22:219-37. [PMID: 27291888 PMCID: PMC4946398 DOI: 10.3350/cmh.2016.0024] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 12/13/2022] Open
Abstract
Advances in the treatment of malignant and inflammatory diseases have developed over time, with increasing use of chemotherapeutic and immunosuppressive agents of a range of drug classes with varying mechanism and potency in their effects on the immune system. These advances have been met with the challenge of increased risk of hepatitis B virus (HBV) reactivation in susceptible individuals. The magnitude of risk of HBV reactivation is associated with the individual’s HBV serological status and the potency and duration of immunosuppression. Individuals with chronic hepatitis B (CHB) and previously infected but serologically cleared HBV infection are both susceptible to HBV reactivation. HBV reactivation in the setting of immunosuppression is a potentially life threatening condition leading to liver failure and death in extreme cases. It is important to recognize that HBV reactivation in the setting of immunosuppression is potentially preventable. Therefore, identification of patients at risk of HBV reactivation and institution of prophylactic antiviral therapy prior to initiation of immunosuppression is essential.
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Affiliation(s)
- Venessa Pattullo
- Department of Gastroenterology, Royal North Shore Hospital, Sydney, Australia
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Yilmaz V, Aliosmanoglu İ, Erbis H, Ulger B, Cetinkaya R, Suleymanlar G, Kocak H. Effects of hepatitis B surface antigen (HBsAg) positivity of donors in HBsAg(+) renal transplant recipients: comparison of outcomes with HBsAg(+) and HBsAg(−) donors. Transpl Infect Dis 2016; 18:55-62. [DOI: 10.1111/tid.12482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/20/2015] [Accepted: 09/25/2015] [Indexed: 12/14/2022]
Affiliation(s)
- V.T. Yilmaz
- Department of Internal Medicine; Division of Nephrology; Akdeniz University Medical School; Antalya Turkey
| | - İ. Aliosmanoglu
- Department of General Surgery; Akdeniz University Medical School; Antalya Turkey
| | - H. Erbis
- Department of General Surgery; Akdeniz University Medical School; Antalya Turkey
| | - B.V. Ulger
- Department of General Surgery; Dicle University Medical School; Diyarbakir Turkey
| | - R. Cetinkaya
- Department of Internal Medicine; Division of Nephrology; Akdeniz University Medical School; Antalya Turkey
| | - G. Suleymanlar
- Department of Internal Medicine; Division of Nephrology; Akdeniz University Medical School; Antalya Turkey
| | - H. Kocak
- Department of Internal Medicine; Division of Nephrology; Akdeniz University Medical School; Antalya Turkey
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21
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Stratta P, Bruschetta E, Minisini R, Barbè MC, Cornella C, Tognarelli G, Cena T, Magnani C, Fenoglio R, Toffolo K, Airoldi A, Pirisi M. Prevalence and clinical relevance of occult hepatitis B virus infection in patients on the waiting list for kidney transplantation. Transplant Proc 2015; 41:1132-7. [PMID: 19460498 DOI: 10.1016/j.transproceed.2009.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Occult hepatitis B virus (HBV) infection can be defined as the long-lasting persistence of viral genomes in the liver tissue, and sometimes also in the serum at low levels of viremia in individuals with undetectable HBV surface antigen (HBsAg). Viral replication can be reactivated by immunosuppressive therapies or immunologic diseases, leading to the development of typical hepatitis B. METHODS All patients on the waiting list for renal transplantation at the only 2 transplant centers in our region (Piemonte, Italy) were checked for the presence of occult HBV infection by an highly sensitive quantitative HBV-DNA polymerase chain reaction (PCR) assay (nested PCR); the only exclusion criterion was HBsAg-positivity. The enrollment lasted from October 1, 2006, to May 31, 2007. The prospective follow-up will continue for 5 years. RESULTS HBV-DNA sequences were detected in blood samples from 10 of 300 cases examined (3.3%), being more frequent among Asian (1/3; 33.3%) and African (1/16; 6.25%) subjects as compared with the Caucasians (8/281; 2.8%; P = .011), among anti-hepatitis C virus (HCV) positive versus HCV negative patients (3/32 [9.3%] vs 7/268 [2.6%]; P = .004) and mainly among patients with a previous history of overt liver diseases (3/22 [14%] vs 7/278 [2.5%]; P = .019). HBV-DNA sequences became undetectable at 1 month after renal transplantation in 3 patients; the follow-up is in progress for these and the other patients. CONCLUSION Occult HBV infection occurs in patients undergoing renal transplantation. Longer observation and prospective studies will clarify the clinical impact of this occult infection on transplant outcomes and the possibility of viral reactivation related to immunosuppressive therapy.
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Affiliation(s)
- P Stratta
- Department of Clinical and Experimental Medicine, Amedeo Avogadro University, Novara, Italy.
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Moal V, Motte A, Vacher-Coponat H, Tamalet C, Berland Y, Colson P. Considerable decrease in antibodies against hepatitis B surface antigen following kidney transplantation. J Clin Virol 2015; 68:32-6. [DOI: 10.1016/j.jcv.2015.04.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/31/2015] [Accepted: 04/11/2015] [Indexed: 01/15/2023]
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Pattullo V. Hepatitis B reactivation in the setting of chemotherapy and immunosuppression - prevention is better than cure. World J Hepatol 2015; 7:954-967. [PMID: 25954478 PMCID: PMC4419099 DOI: 10.4254/wjh.v7.i7.954] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 01/16/2015] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
Due to the inherent relationship between the immune system and the hepatitis B virus (HBV) in exposed and infected individuals, immunomodulation associated with the treatment of solid tumours, haematological malignancies and inflammatory disorders has been linked to HBV reactivation (HBVr). Reactivation of HBV infection in the setting of chemotherapy and immunosuppression may lead to fulminant liver failure and death, but there is a cumulative body of evidence that these are potentially preventable adverse outcomes. As chronic hepatitis B is largely asymptomatic but also endemic worldwide, clinicians caring for patients requiring chemotherapy or immunosuppression need to be vigilant of the potential for HBVr in susceptible individuals. Serological screening and prophylactic and pre-emptive antiviral treatment with a nucleos(t)ide analogue should be considered in appropriate settings. Hepatitis B prevalence is examined in this review article, as are the risks of HBVr in patients receiving chemo- and immunosuppressive therapy. Recommendations regarding screening, monitoring and the role of antiviral prophylaxis are outlined with reference to current international associations’ guidelines and the best available evidence to date.
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Fontenele AMM, Gainer JBF, da Silva e Silva DV, Cruz Santos MD, Salgado JV, Salgado Filho N, Ferreira ASP. Occult hepatitis B among patients with chronic renal failure on hemodialysis from a capital city in northeast Brazil. Hemodial Int 2015; 19:353-9. [DOI: 10.1111/hdi.12285] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
| | | | | | - Max Diego Cruz Santos
- Clinical Research Center; University Hospital, Federal University of Maranhão; São Luís Brazil
| | - João Victor Salgado
- Kidney Disease Prevention Center; University Hospital and Department of Physiological Sciences, Federal University of Maranhão; São Luís Brazil
| | - Natalino Salgado Filho
- Nephrology Service; University Hospital, Federal University of Maranhão; São Luís Brazil
- Department of Medicine I; Federal University of Maranhão; São Luís Brazil
| | - Adalgisa Sousa Paiva Ferreira
- Clinical Research Center; University Hospital, Federal University of Maranhão; São Luís Brazil
- Department of Medicine I; Federal University of Maranhão; São Luís Brazil
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25
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Ridruejo E. Antiviral treatment for chronic hepatitis B in renal transplant patients. World J Hepatol 2015; 7:189-203. [PMID: 25729474 PMCID: PMC4342601 DOI: 10.4254/wjh.v7.i2.189] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 10/17/2014] [Accepted: 11/19/2014] [Indexed: 02/06/2023] Open
Abstract
Chronic hepatitis B infection is frequent in renal transplant patients. It negatively impacts long term outcomes reducing graft and patient survival. Current guidelines clearly define who needs treatment, when to start, what is the first line therapy, how to monitor treatment response, when to stop, and how patients must be controlled for its safety. There is some data showing a favorable safety and efficacy profile of nucleos(t)ide analogue (NUC) treatment in the renal transplant setting. Entecavir, a drug without major signs of nephrotoxicity, appears to be the first option for NUC naïve patients and tenofovir remains the preferred choice for patients with previous resistance to lamivudine or any other NUC. Renal transplant recipients under antiHBV therapy should be monitored for its efficacy against HBV but also for its safety with a close renal monitoring. Studies including a large number of patients with long term treatment and follow up are still needed to better demonstrate the safety and efficacy of newer NUCs in this population.
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Abstract
Patients with chronic HBV infection are at risk of reactivation of HBV should they require immunosuppressive therapies for a variety of clinical settings, including chemotherapy for patients with cancer, immunosuppression for solid organ and stem cell transplant recipients, and use of anti-CD20 antibodies, TNF inhibitors, or corticosteroids in patients with oncological, gastrointestinal, rheumatological or dermatological conditions. The key to preventing HBV reactivation is the identification of patients with HBV infection prior to immunosuppressive therapy, initiation of prophylactic antiviral therapy in patients at moderate or high risk of HBV reactivation, and close monitoring of other patients so that antiviral therapy can be initiated at the first sign of HBV reactivation. Unfortunately, many patients infected with HBV are unaware of their infection or risk factors, and physicians often do not have sufficient time to systematically assess patients for risk factors for HBV prior to starting immunosuppressive therapy. In this article, we review the incidence, risk factors and outcomes of HBV reactivation, and the efficacy of antiviral therapy in preventing its occurrence. We also propose an algorithm for managing patients with HBV infection who require immunosuppressive therapy.
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Nishimura K, Kishikawa H, Yoshida Y, Ueda N, Nakazawa S, Yamanaka K, Hirai T, Ichikawa Y. Clinical and Virologic Courses of Hepatitis B Surface Antigen-Negative and Hepatitis B Core or Hepatitis B Surface Antibody-Positive Renal Transplant Recipients. Transplant Proc 2013; 45:1600-2. [DOI: 10.1016/j.transproceed.2013.01.093] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 01/24/2013] [Indexed: 10/26/2022]
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Abstract
Hepatitis B virus (HBV) infection is more frequent in immune deficient populations than in the general population with lower rates of spontaneous recovery in acute cases, thus explaining the high rate of chronic infection and the increased risk of cirrhosis and hepatocellular carcinoma, resulting in increased morbidity-mortality in these patients. The negative impact of immune deficiency on chronic HBV infection is related to two non-exclusive factors: (i) high viral load enhances the progression of fibrosis and may result in a rare severe liver disease called fibrosing cholestatic hepatitis, which reflects the direct toxicity of high levels of HBV proteins; (ii) The pathobiology of HBV infection is mainly immune-mediated via HBV-specific T lymphocytotoxicity. The reduction or discontinuation of immune deficiency may result in severe liver disease including fulminant hepatitis from immune restoration. Thus, immune deficiency enhances the hepatitis B viral load, which results in the progression of fibrosis and/or acute exacerbation of underlying liver disease (HBV reactivation) on one hand, whereas reduction in immune deficiency may also be harmful because of immune restoration on the other hand. This double-edged sword explains why the diagnosis and evaluation of the impact of HBV infection on the liver must be especially rigorous in cases of immune deficiency whatever the cause: transplantation, oncology, haematology, internal medicine (rheumatology, gastroenterology …) or HIV infection, and why pre-emptive therapy by HBV nucleos(t)ide analogues should be considered for all HBV-infected patients.
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Affiliation(s)
- Stanislas Pol
- Inserm U.1016, Unité d'Hépatologie, APHP Hôpital Cochin, Université Paris Descartes, Paris, France.
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30
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Asahina Y, Izumi N, Oketani M, Kumada H, Kurosaki M, Koike K, Suzuki F, Takikawa H, Tanaka A, Tanaka E, Tanaka Y, Tsubouchi H, Hayashi N, Hiramatsu N, Yotsuyanagi H. Guidelines for the management of hepatitis B virus infection. ACTA ACUST UNITED AC 2013. [DOI: 10.2957/kanzo.54.402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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31
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Kanaan N, Kabamba B, Maréchal C, Pirson Y, Beguin C, Goffin E, Hassoun Z. Significant rate of hepatitis B reactivation following kidney transplantation in patients with resolved infection. J Clin Virol 2012; 55:233-8. [DOI: 10.1016/j.jcv.2012.07.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 07/21/2012] [Accepted: 07/25/2012] [Indexed: 02/07/2023]
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32
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Mahboobi N, Tabatabaei S, Blum H, Alavian S. Renal grafts from anti-hepatitis B core-positive donors: a quantitative review of the literature. Transpl Infect Dis 2012; 14:445-51. [DOI: 10.1111/j.1399-3062.2012.00782.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 01/08/2012] [Accepted: 04/26/2012] [Indexed: 12/29/2022]
Affiliation(s)
| | - S.V. Tabatabaei
- Gastroenterologishe Klinik; Westfälische Wilhelms-Universität Münster; St.-Marien-Hospital GmbH; Lünen; Germany
| | - H.E. Blum
- Department of Medicine II; University Hospital Freiburg; Freiburg; Germany
| | - S.M. Alavian
- Baqiyatallah Research Center for Gastroenterology and Liver Disease; Baqiyatallah University of Medical Sciences; Tehran; Iran
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33
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Abramson A, Menter A, Perrillo R. Psoriasis, hepatitis B, and the tumor necrosis factor-alpha inhibitory agents: a review and recommendations for management. J Am Acad Dermatol 2012; 67:1349-61. [PMID: 22727462 DOI: 10.1016/j.jaad.2012.04.036] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 04/04/2012] [Accepted: 04/11/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Tumor necrosis factor inhibitory agents are currently considered to be contraindicated in psoriatic patients with hepatitis B. OBJECTIVE We aim to provide guidance to dermatologists on the use of tumor necrosis factor inhibitor therapy in these patients. METHODS The current literature was reviewed regarding the use of tumor necrosis factor-alpha inhibitory agents (etanercept, adalimumab, and infliximab) in psoriatic patients with particular reference to hepatitis B infection. RESULTS Tumor necrosis factor-alpha inhibitor therapy may result in reactivated hepatitis B in hepatitis B surface antigen-positive patients with psoriasis. This also occurs, although less frequently in patients with an isolated positive hepatitis B core antibody. Thus, all psoriasis patients should be screened for hepatitis B surface antigen plus hepatitis B core antibody prior to the initiation of tumor necrosis factor-alpha inhibitor therapy. Infliximab has been associated with more reactivation cases than the other 2 agents and fatalities have been reported with this agent. Evidence is presented that the risk of reactivation can be greatly minimized or eliminated by early or pre-emptive antiviral therapy. LIMITATIONS The data is largely based on small case series that are retrospective in nature. CONCLUSIONS Hepatitis B screening is essential prior to the initiation of tumor necrosis factor-alpha inhibitor therapy. Psoriatic patients found to be hepatitis B surface antigen or hepatitis B core antibody-positive should be referred to an appropriate specialist for evaluation and therapy. This would allow for the safe use of tumor necrosis factor-alpha inhibitors in psoriatic patients despite recently published guidelines to the contrary.
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Affiliation(s)
- Amanda Abramson
- Division of Dermatology, Baylor University Medical Center, Dallas, Texas, USA
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34
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Cukuranovic J, Ugrenovic S, Jovanovic I, Visnjic M, Stefanovic V. Viral infection in renal transplant recipients. ScientificWorldJournal 2012; 2012:820621. [PMID: 22654630 PMCID: PMC3357934 DOI: 10.1100/2012/820621] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 01/10/2012] [Indexed: 12/18/2022] Open
Abstract
Viruses are among the most common causes of opportunistic infection after transplantation. The risk for viral infection is a function of the specific virus encountered, the intensity of immune suppression used to prevent graft rejection, and other host factors governing susceptibility. Although cytomegalovirus is the most common opportunistic pathogen seen in transplant recipients, numerous other viruses have also affected outcomes. In some cases, preventive measures such as pretransplant screening, prophylactic antiviral therapy, or posttransplant viral monitoring may limit the impact of these infections. Recent advances in laboratory monitoring and antiviral therapy have improved outcomes. Studies of viral latency, reactivation, and the cellular effects of viral infection will provide clues for future strategies in prevention and treatment of viral infections. This paper will summarize the major viral infections seen following transplant and discuss strategies for prevention and management of these potential pathogens.
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Affiliation(s)
| | | | - Ivan Jovanovic
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia
| | - Milan Visnjic
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia
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Abstract
Chronic hepatitis B virus (HBV) infection is a complex clinical entity frequently associated with cirrhosis and hepatocellular carcinoma (HCC). The persistence of HBV genomes in the absence of detectable surface antigenemia is termed occult HBV infection. Mutations in the surface gene rendering HBsAg undetectable by commercial assays and inhibition of HBV by suppression of viral replication and viral proteins represent two fundamentally different mechanisms that lead to occult HBV infections. The molecular mechanisms underlying occult HBV infections, including recently identified mechanisms associated with the suppression of HBV replication and inhibition of HBV proteins, are reviewed in detail. The availability of highly sensitive molecular methods has led to increased detection of occult HBV infections in various clinical settings. The clinical relevance of occult HBV infection and the utility of appropriate diagnostic methods to detect occult HBV infection are discussed. The need for specific guidelines on the diagnosis and management of occult HBV infection is being increasingly recognized; the aspects of mechanistic studies that warrant further investigation are discussed in the final section.
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36
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Abstract
Chronic hepatitis B virus (HBV) infection is a complex clinical entity frequently associated with cirrhosis and hepatocellular carcinoma (HCC). The persistence of HBV genomes in the absence of detectable surface antigenemia is termed occult HBV infection. Mutations in the surface gene rendering HBsAg undetectable by commercial assays and inhibition of HBV by suppression of viral replication and viral proteins represent two fundamentally different mechanisms that lead to occult HBV infections. The molecular mechanisms underlying occult HBV infections, including recently identified mechanisms associated with the suppression of HBV replication and inhibition of HBV proteins, are reviewed in detail. The availability of highly sensitive molecular methods has led to increased detection of occult HBV infections in various clinical settings. The clinical relevance of occult HBV infection and the utility of appropriate diagnostic methods to detect occult HBV infection are discussed. The need for specific guidelines on the diagnosis and management of occult HBV infection is being increasingly recognized; the aspects of mechanistic studies that warrant further investigation are discussed in the final section.
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37
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Berger A, Stürmer M, Doerr HW. Case report: risk of virus infection after accidental blood inoculation from a multi-infected AIDS patient. J Med Virol 2012; 84:897-900. [PMID: 22499012 DOI: 10.1002/jmv.23286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Infections caused by blood-borne viruses such as hepatitis B and C and the human immunodeficiency virus (HIV) are associated commonly with needlestick injuries, especially in a hospital setting. A prospective investigation was conducted on a medical doctor who suffered an accidental needlestick injury during blood collection from a patient with AIDS. The patient's blood contained 195,000 copies of HIV RNA, 1 × 10(6) IU hepatitis C virus (HCV) RNA, and >10(7) copies of parvovirus B19 DNA per 1 ml plasma. It was positive for cytomegalovirus virus and evidence of a resolved hepatitis B virus (HBV) infection was found. HCV viremia was detected in the physician 15 days later and was not resolved by seroconversion after 57 days. HIV infection was not transmitted, possibly because of the immediate use of anti-HIV prophylactic drugs after exposure. Parvovirus B19 infection was presumably prevented by pre-existing specific antibodies in the patient. Considering that many HIV carriers are coinfected with hepatitis B and C viruses, this case report support the knowledge that the risk of HCV transmission from a patient with AIDS is greater than that of HIV.
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Affiliation(s)
- Annemarie Berger
- Institute of Medical Virology, Hospital of Johann-Wolfgang-Goethe University, Frankfurt/M, Germany.
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38
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Kalia H, Fabrizi F, Martin P. Hepatitis B virus and renal transplantation. Transplant Rev (Orlando) 2011; 25:102-9. [PMID: 21530218 DOI: 10.1016/j.trre.2011.02.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Hepatitis B virus (HBV) infection remains an important cause of liver disease in the renal transplant (RT) population, potentially diminishing survival. Consequences of HBV infection after RT include progression to decompensated cirrhosis and an increased risk of hepatocellular carcinoma. Although precautions initially recommended by the Centers for Diseases Control and Prevention 30 years ago have substantially reduced HBV transmission within hemodialysis units, acute HBV outbreaks continue to be reported in patients with chronic kidney disease on maintenance hemodialysis. In addition, immigration from areas of high HBV prevalence implies that HBV-infected organs with chronic kidney disease will continue to enter the RT pool. Fortunately, the advent of oral therapy for HBV infection now reduces the risk of HBV progression post-RT.
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Affiliation(s)
- Harmit Kalia
- Division of Hepatology, Albert Einstein College of Medicine, Bronx, NY 10461, USA.
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39
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Abstract
Reactivation of hepatitis B is characterized by a sudden increase in hepatitis B virus (HBV) replication in a patient with prior evidence of resolved or inactive HBV infection. Although HBV reactivation can occur spontaneously, it usually occurs after chemotherapy, immunosuppression (organ transplantation) or an alteration in immune function (therapy for autoimmune disease, human immunodeficiency virus infection). The clinical presentation cases can vary, ranging from a subclinical, asymptomatic course to severe acute hepatitis and even death. Although reactivation of HBV is mainly found in HBsAg-positive patients, it can be observed in serologically recovered anti-hepatitis B core antibody (HBc)-positive, HBsAg-negative patients. Serum HBV DNA typically increases during immune suppression, followed by a disease flare and HBV DNA clearance following immune restoration after immune suppression is stopped. In organ transplant recipients, without immune reconstitution, high HBV DNA levels can lead to fibrosing cholestatic hepatitis related to the direct cytopathic effect of HBV. Several randomized, controlled trials and meta-analyses have shown that reactivation can be prevented by lamivudine prophylaxis. Screening for HBsAg and anti-HBc should be performed before beginning immunosuppressive treatment and routine prophylaxis is recommended in HBsAg-positive patients. The optimal duration of prophylaxis remains to be determined. In anti-HBc-positive patients with or without anti-hepatitis B surface antigen, alanine transaminase and HBV DNA levels should be closely monitored and antiviral therapy should be started when HBV reactivation is confirmed. The use of new more potent nucleos(t)ides analogues with lower resistance rates would seem to be logical; however, experience with these drugs in the prophylaxis and treatment of severe HBV reactivation is limited.
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Affiliation(s)
- Bruno Roche
- AP-HP, Hopital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
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40
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Lubel JS, Angus PW. Hepatitis B reactivation in patients receiving cytotoxic chemotherapy: diagnosis and management. J Gastroenterol Hepatol 2010; 25:864-71. [PMID: 20546439 DOI: 10.1111/j.1440-1746.2010.06243.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Nearly one third of the world's population have been infected with hepatitis B and the virus is endemic in many Asian countries. With increasing life expectancy and the expected global increase in cancer, chemotherapy induced reactivation of hepatitis B is likely to become an increasing problem. Patients with significant levels of hepatitis B virus (HBV) DNA in serum prior to chemotherapy and patients receiving intensive chemotherapy for hematological malignancies appear particularly at risk. Most patients who suffer reactivation of hepatitis B are positive for hepatitis B surface antigen (HBsAg) prior to chemotherapy and are therefore easily identifiable by routine screening. In addition, the very large population of patients who have been exposed to the virus and have apparently cleared the virus as assessed by serological testing (HBsAg negative/hepatitis B core antibody [HBcAb] positive) may also be at risk of reactivation. These patients should be monitored and in some cases receive prophylaxis during chemotherapy. Published experience with antiviral prophylaxis has largely been limited to the nucleoside analogue, lamivudine. The commencement of antiviral prophylaxis prior to chemotherapy and its continuation until restitution of normal host immunity is the cornerstone to effective prevention of hepatitis B reactivation. This review summarizes the important issues related to HBV reactivation and suggests an algorithm for managing these patients in the clinical setting.
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Affiliation(s)
- John S Lubel
- Department of Hepatology, Box Hill Hospital, Box Hill, Melbourne, Victoria, Australia.
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41
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Management of HBV infection during immunosuppressive treatment. Mediterr J Hematol Infect Dis 2009; 1:e2009025. [PMID: 21415959 PMCID: PMC3033125 DOI: 10.4084/mjhid.2009.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2009] [Accepted: 12/21/2009] [Indexed: 12/21/2022] Open
Abstract
The literature on hepatitis B virus (HBV) in immunocompromised patients is heterogeneous and refers mainly to the pre-antivirals era. Currently, a rational approach to the problem of hepatitis B in these patients provides for: a) the evaluation of HBV markers and of liver condition in all subjects starting immunosuppressive therapies (baseline), b) the treatment with antivirals (therapy) of active carriers, c) the pre-emptive use of antivirals (prophylaxis) in inactive carriers, especially if they are undergoing immunosuppressive therapies judged to be at high risk, d) the biochemical and HBsAg monitoring (or universal prophylaxis in case of high risk immunosuppression, as in onco-haematologic patients and bone marrow transplantation) in subjects with markers of previous contact with HBV (HBsAg-negative and antiHBc-positive), in order to prevent reverse seroconversion. Moreover in solid organ transplants it is suggested a strict adherence to the criteria of allocation based on the virological characteristics of both recipients and donors and the universal prophylaxis or therapy with nucleos(t)ides analogs
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Abstract
The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.
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Palmore TN, Shah NL, Loomba R, Borg BB, Lopatin U, Feld JJ, Khokhar F, Lutchman G, Kleiner DE, Young NS, Childs R, Barrett AJ, Liang TJ, Hoofnagle JH, Heller T. Reactivation of hepatitis B with reappearance of hepatitis B surface antigen after chemotherapy and immunosuppression. Clin Gastroenterol Hepatol 2009; 7:1130-7. [PMID: 19577007 PMCID: PMC2779698 DOI: 10.1016/j.cgh.2009.06.027] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 06/05/2009] [Accepted: 06/20/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS HBV infection may reactivate in the setting of immunosuppression, although the frequency and consequences of HBV reactivation are not well known. We report 6 patients who experienced loss of serologic markers of hepatitis B immunity and reappearance of HBsAg in the serum as a result of a variety of acquired immune deficiencies. METHODS Between 2000 and 2005, six patients with reactivation of hepatitis B were seen in consultation by the Liver Diseases Branch at the Clinical Center, National Institutes of Health. The course and outcome of these 6 patients were reviewed. RESULTS All 6 patients developed reappearance of HBsAg and evidence of active liver disease after stem cell transplantation (n = 4), immunosuppressive therapy (n = 1), or change in human immunodeficiency virus antiretroviral regimen (n = 1), despite having antibody to HBsAg (anti-HBs) or antibody to hepatitis B core antigen (anti-HBc) without HBsAg before. All 6 patients developed chronic hepatitis B, 2 patients transmitted hepatitis B to their spouses, and 1 patient developed cirrhosis. The diagnosis of hepatitis B reactivation was frequently missed or delayed and often required interruption of the therapy for the underlying condition. None of the patients received antiviral prophylaxis against HBV reactivation. CONCLUSIONS Serologic evidence of recovery from hepatitis B infection does not preclude its reactivation after immunosuppression. Screening for serologic evidence of hepatitis B and prophylaxis of those with positive results by using nucleoside analogue antiviral therapy should be provided to individuals in whom immunosuppressive therapy is planned.
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Affiliation(s)
- Tara N. Palmore
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | | | | | | | | | | | | | | | - David E. Kleiner
- National Cancer Institute, National Institutes of Health, Bethesda, Md
| | - Neal S. Young
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Richard Childs
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Md
| | - A. John Barrett
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Md
| | - T. Jake Liang
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Md
| | - Jay H. Hoofnagle
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Md
| | - Theo Heller
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Md
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Kalyoncu U, Yonem O, Calguneri M, Ersoy O, Karadag O, Akdogan A, Bilgen SA, Kiraz S, Ertenli I, Bayraktar Y. Prophylactic use of lamivudine with chronic immunosuppressive therapy for rheumatologic disorders. Rheumatol Int 2008; 29:777-80. [PMID: 19037603 DOI: 10.1007/s00296-008-0790-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2008] [Accepted: 09/24/2008] [Indexed: 01/11/2023]
Abstract
The objective of this study was to report our experience concerning the effectiveness of the prophylactic administration of lamivudine in hepatitis B virus surface antigen (HBs Ag) positive patients with rheumatologic disease. From June 2004 to October 2006, 11 HBs Ag positive patients with rheumatologic diseases, who were on both immunosuppressive and prophylactic lamivudine therapies, were retrospectively assessed. Liver function tests, hepatitis B virus (HBV) serologic markers, and HBV DNA levels of the patients during follow-up were obtained from hospital file records. Eleven patients (six male) with median age 47 years (range 27-73), median disease duration 50 months (range 9-178) and median follow-up period of patients 13.8 months (range 5-27) were enrolled in this study. Lamivudine therapy was started 3-7 days prior to immunosuppressive therapy in all patients. Baseline, liver function tests were elevated in two patients (fourth patient: ALT:122 IU/l, AST:111 IU/l, tenth patient:ALT:294 IU/l, AST:274 IU/l, with minimal changes in the liver biopsy in both). Shortly after treatment their tests normalized and during follow-up period none of the patients had abnormal liver function tests. In four patients HBV DNA levels were higher than normal at baseline. Two of these normalized and the others increased later. In three additional patients, HBV DNA levels were increased during follow-up. None of the patients had significant clinical sings of HBV activation. Lamivudine was well tolerated and was continued in all patients. Prophylactic administration of lamivudine in patients who required immunosuppressive therapy seems to be safe, well tolerated and effective in preventing HBV reactivation.
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Lau GKK. Hepatitis B reactivation after chemotherapy: two decades of clinical research. Hepatol Int 2008; 2:152-62. [PMID: 19669300 PMCID: PMC2716860 DOI: 10.1007/s12072-008-9056-3] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Accepted: 01/23/2008] [Indexed: 02/06/2023]
Abstract
Hepatitis due to hepatitis B virus reactivation after cytotoxic or immunosuppressive therapy is a serious cause of liver-related morbidity and mortality. With the characterization of the underlying pathogenesis, much progress in the management of this important clinical problem has been made in the past 2 decades. By year 2008, it is mandatory to screen for hepatitis B surface antigen status before initiating intensive chemotherapy or immunosuppressive therapy. All those who are hepatitis B surface antigen positive should be started on preemptive nucleos(t)ide analogues. However, there remains important issues, such as the type and duration of nucleos(t)ide analogue therapy, which need to be understood. As not all hepatitis B surface antigen-positive patients will suffer from HBV reactivation, it is therefore useful to identify risk factors related to HBV reactivation so that patients will not be treated unnecessarily with nucleos(t)ide analogues. To date, a high baseline level of viral replication, as reflected by high serum HBV DNA level, positive serum hepatitis B e antigen, and a high intrahepatic covalently closed circular DNA level, is the most important predictor for HBV reactivation. Recently, there has been an increased awareness of reactivation of occult hepatitis B virus, especially in hepatitis B virus endemic area, such as the Asia-Pacific region. Careful epidemiological study will be needed to clarify the impact of occult hepatitis B infection in patients treated with cytotoxic or immunosuppressive therapy.
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Affiliation(s)
- George K K Lau
- Department of Medicine, The University of Hong Kong, Room 1838, Block K, Queen Mary Hospital, 102 Pokfulum Road, Hong Kong, Hong Kong SAR China,
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Barclay S, Pol S, Mutimer D, Benhamou Y, Mills PR, Hayes PC, Cameron S, Carman W. Erratum to ‘The management of chronic hepatitis B in the immunocompromised patient: Recommendations from a single topic meeting’ [J. Clin. Virol. 41 (4) 2008 243–254]. J Clin Virol 2008; 42:104-15. [DOI: 10.1016/j.jcv.2008.03.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Lubel JS, Testro AG, Angus PW. Hepatitis B virus reactivation following immunosuppressive therapy: guidelines for prevention and management. Intern Med J 2007; 37:705-12. [PMID: 17894766 DOI: 10.1111/j.1445-5994.2007.01479.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
It is well known that immunosuppressive drugs or cancer chemotherapy can stimulate replication of hepatitis B virus (HBV) and precipitate severe flares of HBV infection. The risk of this syndrome of 'reactivation hepatitis B' is highest in haematopoietic stem cell or solid organ transplant recipients and in those undergoing chemotherapy for haematological malignancies; however, it has been described following almost any form of immunosuppressive treatment. Fortunately, it can be largely prevented by prophylactic therapy with oral anti-HBV nucleoside/nucleotide analogues. Importantly, chronic HBV infection is usually asymptomatic, and most patients at risk are likely to be unaware that they carry the infection. Thus, the key to avoiding this potentially fatal complication of immunosuppressive treatment is to ensure that all patients at risk of chronic HBV infection are screened for the disease before commencing immunosuppressive treatment or chemotherapy.
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Affiliation(s)
- J S Lubel
- Victorian Liver Transplant Unit, Department of Gastroenterology, Austin Health, Heidelberg, Victoria, Australia
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Marzano A, Angelucci E, Andreone P, Brunetto M, Bruno R, Burra P, Caraceni P, Daniele B, Di Marco V, Fabrizi F, Fagiuoli S, Grossi P, Lampertico P, Meliconi R, Mangia A, Puoti M, Raimondo G, Smedile A. Prophylaxis and treatment of hepatitis B in immunocompromised patients. Dig Liver Dis 2007; 39:397-408. [PMID: 17382608 DOI: 10.1016/j.dld.2006.12.017] [Citation(s) in RCA: 155] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2006] [Revised: 12/15/2006] [Accepted: 12/18/2006] [Indexed: 02/06/2023]
Abstract
The literature on hepatitis B virus (HBV) in immunocompromised patients is heterogeneous and referred mainly to the pre-antivirals era. Today a rational approach to the problem of hepatitis B in these patients provides for: (a) the evaluation of HBV markers and of liver condition in all subjects starting immunosuppressive therapies (baseline), (b) the treatment with antivirals (therapy) of active carriers, (c) the pre-emptive use of antivirals (prophylaxis) in inactive carriers, especially if they are undergoing immunosuppressive therapies judged to be at high risk, (d) the biochemical and hepatitis B surface antigen (HBsAg) monitoring (or universal prophylaxis, in case of high risk immunosuppression) in subjects with markers of previous contact with HBV (HBsAg negative and anti-HBc positive), in order to prevent reverse seroconversion. Moreover it is suggested a strict adherence to criteria of allocation based on the virological characteristics of both recipients and donors in the general setting of transplants and in liver transplantation the universal prophylaxis with nucleos(t)ides analogues (frequently combined with specific anti-HBV immunoglobulins) in HBsAg positive candidates and in HBsAg negative recipients of anti-HBc positive grafts.
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Affiliation(s)
- A Marzano
- Division of Gastroenterology and Hepatology, AO San Giovanni Battista, Torino, Italy.
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Savas N, Colak T, Yilmaz U, Emiroglu R, Haberal M. Hepatitis B virus reactivation after renal transplantation: report of two cases. Transpl Int 2007; 20:301-4. [PMID: 17291225 DOI: 10.1111/j.1432-2277.2006.00427.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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50
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Gärtner BC, Jung W, Welsch C, Fischinger J, Schubert J, Zeuzem S, Mueller-Lantzsch N, Wend UC, Gerlich WH. Permanent loss of anti-HBc after reactivation of hepatitis B virus infection in an anti-HBs and anti-HBc-positive patient after allogeneic stem cell transplantation. J Clin Virol 2007; 38:146-8. [PMID: 17182277 DOI: 10.1016/j.jcv.2006.03.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2005] [Revised: 01/31/2006] [Accepted: 03/06/2006] [Indexed: 12/18/2022]
Abstract
BACKGROUND Reactivation of a hepatitis B virus (HBV) infection after transplantation is associated with a high morbidity and mortality. HBV infections generally result in anti-HBc persisting lifelong. CASE REPORT A 44-year-old female presented 10 years after allogeneic stem cell transplantation with a chronic hepatitis B. The infection was reactivated from a resolved (anti-HBs and anti-HBc positive) HBV infection acquired some years prior to transplantation. Interestingly, she lost all antibodies to HBV including anti-HBc and is upto now anti-HBc negative. The sequence of the surface and the core gene did not reveal any escape mutations. Thus, the loss of anti-HBc might suggest an immunotolerance of the donor's immune system against HBcAg. CONCLUSION This data illustrate that an HBV infection might be reactivated despite high anti-HBs levels prior to transplantation. Furthermore, this is the first patient in which a complete loss of anti-HBc could be documented. Moreover, since anti-HBc is often used as a screening marker for HBV it should be kept in mind that anti-HBc negative patients with high viremic HBV infection may occur.
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Affiliation(s)
- Barbara C Gärtner
- Institute of Virology 1 and Clinic of Internal Medicine 3, University of Saarland, Medical School, Homburg/Saar, Germany
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