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Safe use of livers from donors with positive hepatitis B core antibody
Cosme Manzarbeitia1, David J Reich, Jorge A Ortiz
1Center for Liver Diseases and Liver Transplant Program, Albert Einstein Medical Center, Philadelphia, PA 19141, USA. manzarbc@einstein.edu
Insights
Using hepatitis B core antibody (HBcAb)-positive donors for liver transplants is safe. Careful monitoring and antiviral therapy (lamivudine and hepatitis B immune globulin) effectively manage hepatitis B virus (HBV) recurrence and de novo infections.
Area of Science:
- Hepatology
- Transplant Surgery
- Infectious Diseases
Background:
- Liver transplantation is a life-saving procedure.
- The use of hepatitis B core antibody (HBcAb)-positive donors in liver transplantation is debated due to potential hepatitis B virus (HBV) transmission risks.
- Standard protocols for managing HBV in recipients of HBcAb-positive donors are evolving.
Purpose of the Study:
- To evaluate the safety and outcomes of liver transplantation using HBcAb-positive donors.
- To assess the incidence of de novo and recurrent HBV infection in recipients of HBcAb-positive donors.
- To determine the efficacy of antiviral prophylaxis and treatment in managing HBV in this patient population.
Main Methods:
- Retrospective analysis of 35 liver transplant recipients who received HBcAb-positive donors and 195 who received HBcAb-negative donors.
- Monitoring of all HBcAb-positive recipients for HBV recurrence using HBV DNA assays.
- Stratification of outcomes based on donor-recipient HBcAb status matching and prophylactic antiviral therapy (lamivudine and hepatitis B immune globulin [HBIG]).
Main Results:
- No de novo HBV was observed in recipients of HBcAb-negative donors.
- Among HBcAb-positive donor recipients, 4/35 died within 3 months without HBV recurrence.
- De novo HBV occurred in 100% of mismatched (HBcAb-positive donor to HBcAb-negative recipient) cases, while recurrent HBV occurred in 7% of matched (HBcAb-positive donor to HBcAb-positive recipient) cases.
- All de novo and recurrent HBV infections were successfully treated with HBIG and lamivudine.
- Survival was 100% for recipients of HBcAb-positive donors for non-HBV-related liver disease.
Conclusions:
- Judicious use of HBcAb-positive donors is safe with appropriate follow-up.
- Antiviral therapy (lamivudine and HBIG) is effective in managing de novo and recurrent HBV infections.
- Lamivudine can be reserved for treatment or selectively used as prophylaxis in HBV-naïve recipients of HBcAb-positive donors.
Abstract:
Thirty-five patients received liver transplants using liver donors who had positive test results for the hepatitis B core antibody (HBcAb). In the same time frame, 195 patients received HBcAb-negative liver donors. Mean follow up for patients receiving HBcAb-positive donors was 25 months. All patients receiving HBcAb-positive donors were monitored for recurrence of hepatitis B (HBV) with HBV DNA assays. There was no de novo HBV in recipients of HBcAb-negative grafts. In the group of patients receiving HBcAb-positive donors, 4 of 35 patients died within 3 months after transplant with no evidence of HBV recurrence at time of death. Four patients were transplanted for HBV-related disease and were postoperatively placed on lamivudine and hepatitis B immune globulin (HBIG). HBV recurrence was seen in one of these patients. Of the remaining 27 patients, three of three mismatched patients (HBcAb-positive donor to HBcAb-negative recipient) developed de novo HBV (100%). Of 24 matched patients (HBcAb-positive donor to HBcAb-positive recipient), only two (7%) developed recurrent HBV allograft reinfection. All de novo and recurrent HBV infections were successfully managed with HBIG and lamivudine therapy. Survival for this subgroup of patients receiving HBcAb-positive donors for non-HBV-related liver disease was 100%. We conclude that the judicious use of HBcAb-positive donors is reasonably safe and associated with low morbidity and mortality, with the appropriate follow-up protocols. Additionally, lamivudine use can be reserved for those cases with de novo or recurrent HBV in the liver allograft, or, selectively, as prophylaxis in those recipients patients who are naïve to HBV and receive an HBcAb-positive donor.