Hepatitis B prophylaxis in living donor liver transplantation: single center experience

Until recently chronic hepatitis B virus (HBV) infection was considered a formal contraindication for liver transplantation, since recurrence of infection without prophylaxis occurs in 75%-90% of the patients. However, the introduction of hepatitis B immunoglobulin (HBIg) plus lamivudine has reduced the reinfection rates of the grafts less than 10%. The purpose of this study is to report our experience in a single transplant center and contribute to arguments about prophylaxis in areas where the prevalence of HBV is high.

From July 2004 to September 2008, 50 living donor liver recipients with HBV were included in our study. Preoperative HBV-DNA was positive in 25 patients and negative in the remaining 25. HBIg was first administered during the unhepatic phase of surgery as intravenous (i.v.) bolus and repeated in daily doses as intramusculary (IM) until seroconversion was achieved. Two different low dose HBIg protocols were used for HBV-DNA negative patients. First 15 patients transplanted until January 2006 received 1200 IU HBIg during the operation. From 2006 onwards, 10 patients who were transplanted received 2000 IU HBIg. HBV-DNA positive patients received 5000 IU HBIg during surgery. Until postoperative anti-HBs levels were above 100 mIU/mL and seroconversion was achieved; patients received maintenance doses of HBIg as detailed below: patients with negative preoperative HBV-DNA who received 1200 HBIg preoperative dose received 300 IU/day, those who received 2000 IU had 500 IU/day, those with DNA positivity had 1000 IU/day of maintenance HBIg. Lamivudine was given to all recipients begining on postoperative day 1.

Three of 15 patients who were HBV-DNA negative and who received 1200 IU HBIg intraoperatively developed HBV reinfections. The following 10 DNA negative patients who received 2000 IU of HBIg prophylaxis during the operation and those 25 patients who were DNA positive and received 5000 IU HBIg did not have any HBV reinfections.

Higher doses of HBIg plus lamivudine therapy is a very effective prophylactic regimen for recipients with pre-operative HBV-DNA positivity in preventing a recurrent HBV infection. For preoperative HBV-DNA negative patients, low doses of HBIg plus lamivudine therapy is a feasable prophylactic option when ease of use, cost and low incidence of side effects are taken into consideration. However, it is still a controversial issue how much the required lowest dose should be and at the same time safe for prophylaxis.