Clinical and Virologic Courses of Hepatitis B Surface Antigen-Negative and Hepatitis B Core or Hepatitis B Surface Antibody-Positive Renal Transplant Recipients

Hepatitis B Virus Reactivation in Kidney Transplant Recipients Treated With Belatacept

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.

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

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.

Hepatitis B virus reactivation in kidney transplant patients with resolved hepatitis B virus infection: Risk factors and the safety and efficacy of preemptive therapy

BACKGROUND

Hepatitis B virus (HBV) reactivation is associated with complications and adverse outcomes in patients with clinically resolved HBV infection who are seronegative for hepatitis B surface antigen (HBs Ag), and seropositive for hepatitis B core antibody (HBc Ab) and/or hepatitis B surface antibody (HBs Ab) before kidney transplantation (KT).

METHODS

We retrospectively analyzed 52 patients with resolved HBV infection who were HBV-DNA negative. HBV-DNA after KT was evaluated, and the occurrence of HBV reactivation and outcomes were monitored. We defined HBV reactivation as seropositivity for HBV-DNA at or above the minimal detection level of 1.0 log IU/mL and treated preemptively (using entecavir) when the HBV-DNA level was at or above 1.3 log IU/mL, in accordance with the Japanese Guidelines for HBV treatment.

RESULTS

Among the 52 patients, the mean age was 57.2 ± 10.8 years. The median HBc Ab titer was 12.8 (interquartile range, 4.6-42.6) cutoff index, and five (9.6%) cases of HBV reactivation occurred. No patients developed graft loss and died due to HBV reactivation. Statistical analysis showed that age and HBc Ab titer were significant risk factors for HBV reactivation (P = .037 and P = .042, respectively). No significant differences were found between graft survival and the presence or absence of HBV reactivation.

CONCLUSION

These results suggest that HBc Ab titer and age could be significant risk factors for HBV reactivation. Resolution of HBV infection did not appear to be associated with patient or graft survival, regardless of whether HBV reactivation occurred, when following our preemptive strategy.

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

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.

Risk of hepatitis B reactivation in hepatitis B surface antigen seronegative and core antibody seropositive kidney transplant recipients

BACKGROUND

Previous contact with Hepatitis B virus (HBV) is common in patients undergoing hemodialysis. Literature has shown conflicting results on the risk of HBV reactivation in kidney transplant (KT) recipients with serologic evidence of past HBV infection.

METHODS

We reviewed 631 consecutive KT recipients and selected 70 patients simultaneously HBsAg negative and anti-HBc positive before KT, regardless of hepatitis B surface antibody (anti-HBs) status. Demographic characteristics, coinfection with other viruses, the presence of a previous KT, induction and maintenance immunosuppression, length of follow up, biopsy-proven acute rejection episodes, incidence of impaired liver function, and causes of graft loss and mortality were collected. Hepatitis B virus reactivation was defined as detection of HBV DNA viral load >2000 IU/mL during follow up. Outcome data included HBV reactivation episodes, graft function, and patient survival.

RESULTS

Median follow-up was 151 months; 91.4% of patients were positive to anti-HBs prior to KT. No patient received HBV prophylaxis and 11 patients (15.7%) received rituximab as part of induction therapy. Anti-HBs titers remained stable in all patients throughout the observation period but two patient showed evidence of HBV reactivation after KT.

CONCLUSION

Hepatitis B virus reactivation in HBsAg-negative and anti-HBc-positive after KT is rare but possible. We suggest evaluating HBV serologies, HBV DNA viral load, and liver enzymes before KT and routinely monitoring serologic HBV markers after KT. As only two patients experienced HBV reactivation, it is neither possible to define risk factors for HBV reactivation nor to evaluate the impact of different immunosuppressants or the benefit of prophylactic regimens. Further studies regarding HBV reactivation in solid organ transplant recipients are necessary.

Incidence of Hepatitis B Viral Reactivation After Kidney Transplantation With Low-Dose Rituximab Administration

BACKGROUND

In hematological malignancy patients intended to receive rituximab, hepatitis B virus (HBV) serology screening, viral reactivation monitoring, are recommended. However, the effect of single-dose rituximab (RIT) on HBV reactivation in kidney transplant patients with previous HBV infection is still unclear.

METHODS

In this retrospective cohort study consisting of 1294 kidney transplant patients, we identified 76 patients showing preoperative hepatitis B surface antigen-negative, hepatitis B core antibody-positive, and HBV-DNA-negative results. A rituximab dose of 200 mg/body was administered to 48 patients, 46 of whom did not receive prophylaxis (RIT+ group). Twenty-eight patients received neither rituximab nor prophylaxis (RIT- group). We monitored HBV-DNA by polymerase chain reaction every 1 to 3 months, and HBV reactivation was defined as detectable HBV-DNA.

RESULTS

HBV reactivation was found in 1 patient in the RIT+ group (2.2%) and 1 patient in the RIT- group (3.6%) at 6 weeks and 5.5 years posttransplant, respectively, but spontaneously cleared. Both patients showed positive hepatitis B surface antibody preoperatively. HBV reactivation was not found in 6 patients lacking anti-hepatitis B surface preoperatively.

CONCLUSIONS

Low-dose RIT administration in kidney transplant patients without prophylaxis is associated with low incidence of HBV reactivation. However, the comparisons among standard-dose RIT, low-dose RIT, and controls with high-quality study design is necessary.