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Liver Transplantation for Hepatitis B in Early Adulthood: Analysis of the United Network for Organ Sharing Database
G Rifai1, A Anani2, I A Hanouneh1
1Department of Pediatric Gastroenterology, The Cleveland Clinic, Cleveland, Ohio.
Insights
Liver transplantation (LT) for young adults with chronic hepatitis B virus (HBV) infection shows poor survival rates, highlighting the need for earlier intervention. Outcomes improved after the implementation of Model for End-stage Liver Disease (MELD) prioritization.
Area of Science:
- Hepatology
- Transplantation Medicine
- Virology
Background:
- Chronic hepatitis B virus (HBV) infection typically has a mild course in children, potentially delaying treatment.
- A subset of patients experience rapid progression to cirrhosis, necessitating liver transplantation (LT) in early adulthood.
- Assessing outcomes in young adults undergoing LT for HBV is crucial for improving patient care.
Purpose of the Study:
- To characterize HBV-positive young adults who underwent LT.
- To evaluate post-transplant patient and graft survival.
- To compare outcomes between the pre- and post-Model for End-stage Liver Disease (MELD) prioritization eras.
Main Methods:
- Retrospective analysis of the United Network for Organ Sharing (UNOS) database (1987-2012).
- Inclusion of young adult patients (18-35 years) with HBV as the primary diagnosis or HBsAg positivity at LT.
- Kaplan-Meier analysis for survival and Cox regression for associated factors.
Main Results:
- 522 HBV-infected subjects underwent LT; average age was 28.4 years.
- Graft failure and infection were leading causes of death; only 58% survived with their first LT.
- Post-MELD era showed higher 5-year patient and graft survival rates compared to the pre-MELD era.
Conclusions:
- Liver transplantation for HBV in young adults is associated with poor outcomes and premature mortality.
- Findings suggest a need for more aggressive HBV evaluation and treatment in pediatric patients.
- Improved outcomes in the post-MELD era may stem from better pre-transplant management and HBV treatments.
Background:
Chronic hepatitis B virus (HBV) infection has a mild course in most children that may delay initiation of treatment even when indicated. Unfortunately, a small number of cases can progress rapidly to cirrhosis, which may require liver transplantation (LT) in early adulthood. The aim of this study was to assess the characteristics of HBV-positive young adults who received LT and to evaluate post-transplant outcomes including patient and graft survival and differences between pre- and post-implementation of Model for End-stage Liver Disease (MELD) prioritization.
Methods:
The United Network for Organ Sharing (UNOS) database review was conducted from 1987 to 2012, and a retrospective analysis was performed on all young adult patients (ages 18-35 years) who underwent LT in the United States with a primary diagnosis of HBV or were seropositive for HBV surface antigen at time of LT. Kaplan-Meier analysis was used to assess patient and graft survival in the pre-MELD and post-MELD eras. Factors associated with survival were identified through the use of Cox regression analysis.
Results:
A total of 522 HBV-infected subjects were included. Average age at time of transplant was 28.4 ± 5.2 years; 60.9% were male, 48.6% were white, the mean body mass index was 25 ± 5.5 kg/m2, diabetes was present in 3.9%, hepatocellular carcinoma (HCC) was present in 4.4%, and 10.4% were on dialysis prior to LT. Median follow-up after first LT was 48.2 months [12.5, 109]. During this time, 174 (33.3%) patients died with a mean age at the time of death of 31.6 ± 7.8 years, including 144 of 522 (28%) after the first LT, 26 of 74 (35%) after the second LT, and 4 of 12 (33%) after the third LT. The most common cause of death was graft failure (27.6%), followed by infection (16.6%). Overall, only 58% of patients were alive with their first LT at last follow-up. Kaplan-Meier analysis revealed worse patient and graft survival after re-transplantation in comparison to initial LT. Three hundred thirty subjects were transplanted in the pre-MELD era and 192 were transplanted in post-MELD era. Obesity, HCC, shorter ventilation use, shorter cold ischemia time, and non-white donor race were significantly more common in the post-MELD era (all with P < .05). Importantly, 5-year patient and graft survival rates were higher in the post-MELD era compared with the pre-MELD era.
Conclusions:
LT in young adults for HBV has poor outcomes and can be associated with premature death. These findings should prompt more aggressive evaluation and treatment for HBV in young patients. Superior outcomes in the post-MELD era compared with the pre-MELD era may be attributed to pre-transplant factors, improved surgical technique, and better treatment options for HBV infection.
