The influence of hepatitis B and C virus infections on patient and allograft outcomes in kidney transplantation

Hepatitis C in non-hepatic solid organ transplant candidates and recipients: A new horizon

Hepatitis C virus (HCV) infection is estimated to affect 130-150 million people globally which corresponds to 2%-3% of the total world population. It remains the leading indication for liver transplant worldwide and has been demonstrated to negatively impact both patient and graft survival following non-hepatic organ transplantation. In the era of interferon-based therapy, although treatment and cure of HCV prior to non-hepatic transplant improved survival, tolerability and low cure rates substantially limited therapy. Interferon (IFN)-based therapy following non-hepatic solid organ transplant, due to the risk of allograft rejection, is generally contraindicated. Rapid advances in IFN-free therapy with direct acting antivirals (DAAs) in the last few years have completely changed the paradigm of hepatitis C therapy. Compared to IFN-based regimens, DAAs have less frequent and less severe adverse effects, shorter durations of therapy, and higher cure rates that are minimally impacted by historically negative predictors of response such as cirrhosis, ethnicity, and post-transplant state. Recent studies have shown that liver transplant (LT) recipients can be safely and effectively treated with DAA combination therapies; although data are limited, many of the principles of therapy in LT may be extrapolated to non-hepatic solid organ transplant recipients. Here we review the data on DAA combination therapies in transplantation, discuss the advantages and disadvantages of pre- vs post-transplant HCV therapy and future directions.

Outcomes of kidney transplantation recipients with hepatitis in the antiviral therapy era: a single-center experience

INTRODUCTION

The use of organs from hepatitis B surface antigen (HBsAg)+ donors could increase the donor pool substantially. However, fulminant hepatic failure requiring urgent liver transplantation or resulting in death has been reported in recipients of HBsAg+ renal transplantation (KT) in pre-nucleos(t)ide analog (NA) era. With effective antiviral therapies such as NAs, it seems feasible to transplant such recipients more safely. To address this issue, we conducted a retrospective, cohort study to evaluate the safety and long-term risks of HBsAg+ KT recipients in the NA era.

METHODS

From December 2006 to January 2013, 112 patients undergoing KT were followed at our institute. We analyzed patient and graft outcomes, hepatitis status (HBsAg status, hepatitis B virus [HBV] DNA level, liver function tests, presence of hepatitis C virus [HCV] co-infection), and graft source (domestic or transplant tourism).

RESULTS

Ninety-two KT recipients were still alive. Nine patients were died of nonhepatic factors. Among 112 patients, there were 19 of 92 recipients alive who were HBsAg+, including 6 patients with HBV and HCV dual infections. Two of 19 patients experienced symptomatic hepatitis, one de novo and the other re-activation. Liver functions of these 2 recipients recovered progressively after introduction of NAs. No recipients in our study had experienced graft loss at the time of analysis.

CONCLUSION

In terms of patient survival and quality of life, KT seems be a safe and feasible therapy of choice for HBsAg+ patients with end-stage renal disease. Infection is easier to prevent than to treat. KT recipients at high risk for HBV reactivation and for complications of HBV, with or without HCV co-infection, may benefit from longer prophylaxis. However, the optimal duration of prophylaxis remains unclear. Furthermore, several issues needed to be solved for clinical concerns, such as frequency and intensity of adverse effects, high costs, increased pill burden, drug-drug interactions, and the emergence of viral resistance variants.

Trend of outcomes in renal transplant recipients with hepatitis B virus: a longitudinal analysis using a national database

INTRODUCTION

Manifestations of hepatitis B virus (HBV) infection in renal transplant (RTx) recipients tend to be worse because of the higher viral load. RTx recipients with Asian heritage have a higher HBV infection rate and have unique characteristics. To date, no large-scale study on the outcomes of Asian RTx recipients has been conducted. Furthermore, there are few longitudinal studies comparing outcomes before and after availability of anti-HBV drugs.

MATERIAL AND METHODS

We conducted a nationwide, population-based study to elucidate patient survival, graft survival, and hepatic outcome (incidence of hepatoma) in Asian RTx recipients. The study includes all RTx recipients in Taiwan from 1997 to 2006. Patients were divided into 2 groups according to HBV infection status to examine the effect of antiviral drug therapy.

RESULTS

In all, 3826 RTx recipients were followed for a mean of 7.4 years, with a mean age of 43.7 years. There were no differences between the HBV and non-HBV groups in patient or graft survival rates. At 5 years after RTx, 89.2% of the patients were still alive and 84.5% RTx recipients were still dialysis free. In the era before anti-HBV drugs were available (1997-2001), patient survival in the HBV and non-HBV groups were similar (P = .614). This result can also be seen in the anti-HBV drug era, from 2002 to 2006 (P = .148). The unusual lack of a significant effect of drug anti-HBV administration on HBV-related mortality in RTx patients may be explained by the short duration of follow-up in the 2 eras. Another explanation may be the confounding effect of the different health status of RTx patients in the pre-anti-HBV drug era, when cardiovascular and infection-related mortality rates were considerably greater than HBV-related mortality rates.

CONCLUSION

These results demonstrate that HBV is not a contraindication for RTx. Asian recipients with HBV can still achieve a similar graft outcome and survival rate compared with those of patients without HBV.

Hepatitis B vaccination in chronic kidney disease patients: a call for novel vaccines

The protective immunization rates in response to hepatitis B vaccination in chronic kidney disease (CKD) patients are lower than response rates in the general population because of genetic and CKD-related factors as well as logistic problems with a proper providing of the recommended vaccination schedules. This review focuses on third-generation vaccines and adjuvanted vaccines commercially introduced in some countries, investigated in clinical trials, especially involving CKD patients or used only in the experimental studies. In order to improve the immunization rate, the use of third-generation vaccines (yeast-derived pre-S2/S HBV vaccines, mammalian cell-derived pre-S2/S HBV vaccines, mammalian cell-derived pre-S1/pre-S2/S HBV vaccines), novel adjuvants (AS04, AS02, phosphorothioate oligodeoxyribonucleotide, hemokinin-1, a polysaccharide based on delta inulin, nano-complex Hep-c, cyclic diguanylate) or immunostimulants for enhancement of immunogenicity of existing recombinant hepatitis B vaccines is tried to improve results of hepatitis B vaccination prior to dialysis commencement or already on renal replacement therapy.