Reduction of azathioprine in renal transplant patients with chronic hepatitis

To determine whether prolonged reduction of azathioprine in renal transplant recipients with chronic hepatitis affected the progression of liver disease without an adverse effect on graft survival we studied all transplant patients with a raised serum glutamic oxaloacetic transaminase level greater than normal for more than 1 year who had azathioprine reduced below 100 mg/day for longer than 1 year. Six HBsAg-positive patients had chronic hepatitis for 67 +/- 7 (SE) months before reduction of azathioprine and were followed for a further 49 +/- 14 months. None of the six patients remitted, 3 patients died from liver disease, and none returned to dialysis. In the group of 12 patients who did not have azathioprine reduced, none remitted, 4 died from liver disease, and none returned to dialysis during a follow-up of 115 +/- 9 months. Seven HBsAG-negative patients had chronic hepatitis for 32 +/- 11 months before reduction of azathioprine and were followed for a further 46 +/- 8 months. One of the seven remitted, none died from liver disease and one returned to dialysis. In the group of 15 patients who did not have azathioprine reduced 5 patients remitted, none died from liver disease, and none returned to dialysis. We conclude that prolonged reduction of azathioprine does not slow the progression of liver disease in renal transplant recipients with HBsAg-positive or HBsAg-negative chronic hepatitis, nor does it predispose to graft failure. However reduction of immunosuppression early in the course of hepatitis B disease may be necessary to prevent adverse long-term sequelae.