Incidence of Hepatitis B Viral Reactivation After Kidney Transplantation With Low-Dose Rituximab Administration. Transplantation. 2018;102:140-145. [PMID: 28665891 DOI: 10.1097/tp.0000000000001870]

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.

Risk Stratification for Hepatitis B Virus Reactivation in Kidney Transplant Recipients With Resolved HBV Infection

The prophylaxis strategy for hepatitis B virus (HBV) reactivation in kidney transplant recipients (KTRs) with resolved HBV infection remains unclear. In this hospital-based retrospective cohort study, consecutive KTRs with resolved HBV infection were screened from the years 2000 through 2020. After excluding confounding conditions, 212 and 45 patients were respectively recruited into Anti-HBs positive and Anti-HBs negative groups. Cumulative incidences of, and subdistribution hazard ratios (SHRs) for HBV reactivation were analyzed after adjusting the competing risk. During a median 8.3 (mean 8.4 ± 4.9) years of follow-up, the 10-year cumulative incidence of HBV reactivation was significantly higher in Anti-HBs negative group when compared to that in Anti-HBs positive group (15.2%, 95% CI: 3.6-26.7 vs. 1.3%, 95% CI: 0.0-3.0; p < 0.001). In multivariable regression analysis, absence of anti-HBs (SHR 14.2, 95% CI: 3.09-65.2; p < 0.001) and use of high-dose steroids, i.e., steroid dose ≥20 mg/day of prednisolone equivalent over 4 weeks (SHR 8.96, 95% CI: 1.05-76.2; p = 0.045) were independent risk factors related to HBV reactivation. Accordingly, the 10-year cumulative incidence of HBV reactivation occurring in patients with two, one and zero risk factors was 42.7% (95% CI: 0.0-87.1), 7.9% (95% CI: 1.2-14.7) and 0%, respectively (p < 0.001). In conclusion, the strategy of HBV antiviral prophylaxis may be defined according to the risk stratification.

Guidelines for Infection Control in the Urological Field, including Urinary Tract Management (revised second edition)

The Committee for the Development of Guidelines for Infection Control in the Urological Field, including Urinary Tract Management of the Japanese Urological Association, together with its systematic review team and external reviewers, have prepared a set of practice guidelines, an abridged version of which is published herein. These guidelines cover the following topics: (i) foundations of infection control, standard precautions, route-specific precautions, and occupational infection control (including vaccines); (ii) the relationship between urologists and infection control; (iii) infection control in urological wards and outpatient clinics; (iv) response to hepatitis B virus reactivation; (v) infection control in urological procedures and examinations; (vi) prevention of infections occurring in conjunction with medical procedures and examinations; (vii) responses to urinary tract tuberculosis and bacillus Calmette-Guérin; (viii) aseptic handling, cleaning, disinfection, and sterilization of urinary tract endoscopes (principles of endoscope manipulation, endoscope lumen cleaning, and disinfection); (ix) infection control in the operating room (principles of hand washing, preoperative rubbing methods, etc.); (x) prevention of needlestick and blood/bodily fluid exposure and response to accidental exposure; (xi) urinary catheter-associated urinary tract infection and purple urinary bag syndrome; and (xii) urinary catheter-associated urinary tract infections in conjunction with home care. In addressing these topics, the relevant medical literature was searched to the extent possible, and content was prepared for the purpose of providing useful information for clinical practice.

Hepatitis B reactivation after kidney transplantation in hepatitis B surface antigen-negative, core antibody-positive recipients

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.

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.

Workup and Management of Immune-Mediated Hepatobiliary Pancreatic Toxicities That Develop During Immune Checkpoint Inhibitor Treatment

Immune checkpoint inhibitor treatment has been approved by the U.S. Food and Drug Administration for the treatment of a wide range of cancer types, including hepatocellular carcinoma. Workup and management of immune-mediated hepatitis, pancreatitis, or cholangitis that develops during immune checkpoint inhibitor treatment can be challenging. Immune-mediated hepatitis can be particularly challenging if patients have underlying viral hepatitis or autoimmune hepatitis. Patients with positive hepatitis B virus DNA should be referred to a hepatologist for antiviral therapy prior to immune checkpoint inhibitor treatment. With untreated hepatitis C virus (HCV) and elevated liver enzymes, a liver biopsy should be obtained to differentiate between HCV infection and immune-mediated hepatitis due to anti-programmed cell death protein 1 (PD-1) therapy. If autoimmune serologies are negative, then this supports a case of immune-mediated hepatitis secondary to anti-PD-1 therapy, rather than autoimmune hepatitis. In this case, an empiric steroid therapy is reasonable; however, if the patient does not respond to steroid therapy in 3-5 days, then liver biopsy should be pursued. The incidence of immune checkpoint-induced pancreatitis is low, but when it does occur, diagnosis is not straightforward. Although routine monitoring of pancreatic enzymes is not generally recommended, when pancreatitis is suspected, serum levels of amylase and lipase should be checked. Once confirmed, a steroid or other immunosuppressant (if steroids are contraindicated) should be administered along with close monitoring, and a slow tapering dosage once the pancreatitis is under control. Patients should then be monitored for recurrent pancreatitis. Finally, immune therapy-related cholangitis involves elevated bilirubin and alkaline phosphatase and, once diagnosed, is managed in the same way as immune-mediated hepatitis. KEY POINTS: Immune-mediated hepatitis, pancreatitis, and cholangitis are found in patients receiving or who have previously received immune checkpoint inhibitors. To work up immune-mediated hepatitis, viral, and autoimmune serologies, liver imaging will help to differentiate immune-mediated hepatitis from hepatitis of other etiology. Hepatology consult may be considered in patients with a history of chronic liver disease who developed hepatitis during immune checkpoint inhibitor treatment. Liver biopsy should be considered to clarify the diagnosis for case in which the hepatitis is refractory to steroid or immunosuppressant treatment. Immune-mediated pancreatitis is treated with steroid or other immunosuppressant with a slow tapering and should be monitored for recurrence.

Infection risks of rituximab versus non-rituximab treatment for rheumatoid arthritis: A systematic review and meta-analysis

OBJECTIVE

The aim of this study was to assess the differences in infection rates between rituximab (RTX) and non-RTX treatment in patients with rheumatoid arthritis (RA).

METHODS

A systematic review and meta-analysis was conducted by searching databases of PubMed, MEDLINE, EMBASE, Web of Science and Cochrane Library through to June 2018. We included studies that compared RTX and non-RTX treatment for patients with RA. Outcome measures were overall infections and serious infections between RTX and non-RTX treatments.

RESULTS

A total of 11 articles, including 9502 patients (4595 with RTX treatment and 4907 with non-RTX treatment) met our inclusion criteria. The results demonstrated that RTX-related all infections and serious infections in RA patients were 43.8% and 4.4%, respectively. Pooled analysis showed no significant differences between RTX and non-RTX treatment groups in overall infections rate (43.3% vs 44.9%; odds ratio [OR] = 0.87; 95% CI = 0.70-1.08) and serious infections rate (4.1% vs 4.6%; OR = 1.05; 95% CI = 0.84-1.31). Subgroup analysis also showed no significant differences in overall infections between RTX versus placebo (OR = 0.98, 95% CI = 0.71-1.33); RTX versus tumor necrosis factor inhibitors (TNFi) (OR = 0.47, 95% CI = 0.30-1.73); RTX plus methotrexate (MTX) versus placebo plus MTX (OR = 0.98, 95% CI = 0.77-1.24), and in serious infections between RTX versus placebo (OR = 1.06, 95% CI = 0.36-3.07); RTX versus TNFi (OR = 1.25, 95% CI = 0.96-1.63); RTX plus MTX versus placebo plus MTX (OR = 0.69, 95% CI = 0.39-1.20).

CONCLUSION

In patients with RA, RTX treatment has no additional risks for infections over non-RTX treatment.

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.

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

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.

Effects of rituximab dose on hepatitis B reactivation in patients with resolved infection undergoing immunologic incompatible kidney transplantation

Sensitized patients received desensitization therapy with rituximab for kidney transplantation. However, the impact of rituximab dose on hepatitis B virus (HBV) reactivation is unknown. Patients who underwent living donor kidney transplantation between 2008 and 2016 were grouped according to rituximab dose (control vs. standard-dose rituximab [375 mg/m²] vs. reduced-dose rituximab [200 mg/body]) for comparison of HBV reactivation. A total of 336 hepatitis B surface antigen (HBsAg)-negative/antibody to hepatitis B core antigen (anti-HBc)-positive patients underwent kidney transplantation, of whom 91 (27.1%) received rituximab for desensitization (57 standard-dose and 34 reduced-dose rituximab). During the study period, eight patients experienced HBV reactivation (three in the control group, five in the standard-dose group). In the standard-dose group, four patients experienced hepatitis flare, and one patient died due to hepatic failure. No HBV reactivation occurred in the reduced-dose group. Standard-dose rituximab significantly decreased hepatitis B surface antigen antibody titer (anti-HBs; −99.8 IU/L) at 12 months, compared with reduced-dose rituximab (−20.1 IU/L) and control (−39.1 IU/L, P = 0.017). Standard-dose rituximab (HR, 10.60; 95% CI, 2.52–44.60; P = 0.001) and anti-HBs < 100 IU/L at transplantation (HR, 9.06; 95% CI, 1.11–74.30; P = 0.04) were independent risk factors for HBV reactivation. Standard-dose rituximab significantly increased HBV reactivation risk for HBsAg-negative/anti-HBc-positive kidney transplant patients.

Pharmacotherapy-Induced Hepatitis B Reactivation Among Patients With Prior Functional Cure: A Systematic Review

OBJECTIVE

To describe and quantify the incidence and morbidity of hepatitis B reactivation (HBVr) secondary to pharmaceutical agents (eg, rituximab, tumor necrosis factor inhibitors, direct-acting antivirals [DAAs] for hepatitis C) among patients with previously resolved hepatitis B infection.

DATA SOURCES

The MEDLINE database was searched from inception through July 2018 using the terms hepatitis B + ( reactivation OR [drug or drug class linked to HBVr]).

STUDY SELECTION AND DATA EXTRACTION

Relevant English-language cohort studies or randomized trials quantifying the incidence of HBVr secondary to pharmacotherapy among patients negative for hepatitis B surface antigen and DNA and positive for hepatitis B core antibody were included.

DATA SYNTHESIS

Among 2045 articles, 102 met inclusion criteria. Receipt of rituximab was associated with the highest risk of HBVr (for oncological indication: 6.2% rate [225/3601 patients]) and subsequent hepatitis (up to 52.4% of all HBVr cases). Biologic agents for autoimmune disease were uncommonly associated with HBVr (2.4%, 56/2338), with only 4 cases of hepatitis, all attributable to rituximab. Reactivation caused by DAAs was rare (0.3%, 28/8398), with no cases of hepatitis. Relevance to Patient Care/Clinical Practice: This review compares and contrasts the incidence and clinical relevance of HBVr for various pharmacotherapies among patients with functionally cured hepatitis B, with discussion of appropriate risk mitigation strategies.

CONCLUSIONS

Among patients with prior functional cure of hepatitis B, prophylactic antiviral therapy is recommended with rituximab administration irrespective of indication because of a high risk for HBVr-associated morbidity. Enhanced monitoring alone is reasonable for patients receiving nonrituximab biologics or DAAs.

Outcomes of kidney transplantation in patients with hepatitis B virus infection: A systematic review and meta-analysis

AIM

To assess outcomes of kidney transplantation including patient and allograft outcomes in recipients with hepatitis B virus (HBV) infection, and the trends of patient's outcomes overtime.

METHODS

A literature search was conducted using MEDLINE, EMBASE and Cochrane Database from inception through October 2017. Studies that reported odds ratios (OR) of mortality or renal allograft failure after kidney transplantation in patients with HBV [defined as hepatitis B surface antigen (HBsAg) positive] were included. The comparison group consisted of HBsAg-negative kidney transplant recipients. Effect estimates from the individual study were extracted and combined using random-effect, generic inverse variance method of DerSimonian and Laird. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42017080657).

RESULTS

Ten observational studies with a total of 87623 kidney transplant patients were enrolled. Compared to HBsAg-negative recipients, HBsAg-positive status was significantly associated with increased risk of mortality after kidney transplantation (pooled OR = 2.48; 95%CI: 1.61-3.83). Meta-regression showed significant negative correlations between mortality risk after kidney transplantation in HBsAg-positive recipients and year of study (slopes = -0.062, P = 0.001). HBsAg-positive status was also associated with increased risk of renal allograft failure with pooled OR of 1.46 (95%CI: 1.08-1.96). There was also a significant negative correlation between year of study and risk of allograft failure (slopes = -0.018, P = 0.002). These associations existed in overall analysis as well as in limited cohort of hepatitis C virus-negative patients. We found no publication bias as assessed by the funnel plots and Egger's regression asymmetry test with P = 0.18 and 0.13 for the risks of mortality and allograft failure after kidney transplantation in HBsAg-positive recipients, respectively.

CONCLUSION

Among kidney transplant patients, there are significant associations between HBsAg-positive status and poor outcomes including mortality and allograft failure. However, there are potential improvements in patient and graft survivals in HBsAg-positive recipients overtime.