Prophylaxis of HBV Re-Infection After Liver Transplantation in NTUH - The Optimal Strategy for a Long-Term Benefit.

Abstract

Background: Although nearly 100% HCV was reactivated after liver transplantation till now, the incidence of HBV reactivation declined after application of lamivudine or HBIG. The most promising results were shown in the combination strategy. The short term (1˜2 years) HBV reactivation rates after liver transplantation are around 3˜15% after treatment with lamivudine and high dose HBIG. There is no long term report about this issue. Also we need to concern the cost of long term use of the expensive HBIG. A lower and effective dose of HBIG would be more economical. Materials and Methods: We performed 439 liver transplantations in a single medical center from Oct. 1989 to Dec. 2012. We designed and introduced our prophylactic protocol of HBV reactivation after liver transplantation for patients with original HBV-related liver disease since Jan. 2000. Our initial combinative protocol includes lamivudine (100mg/day since day 1 postoperatively) and low dose HBIG (10000 IU IV during anhepatic phase, 2000 IU IV/day in the first week postoperatively, 2000 IU IV/week from the 2nd to fourth week postoperatively, and 2000 IU IM/month after that). We shift our prophylactic protocol to withdraw of HBIG 1 year after transplantation since 2009 due to the policy of national insurance. We analyze retrospectively the clinical results of patients treated with this prophylactic protocol after liver transplantation. Results: We included 173 patients in this study with a mean follow up period 66.5±48.4 months (6˜190 months). The 1, 3, 5 years survival rate in our series are 90, 86, and 80.4 %. The serum titer of anti-HBs Ab under this low dose HBIG maintains around 100˜150 IU/ml. The HBV reactivation rate is around 6.3% in our long term HBIG group, but increase to 12% in our one year HBIG withdraw group. The incidence of HBV reactivation with YMDD mutation is 4.2% in our long term HBIG group and 6.7% in our one year HBIG group. Most of our patients with HBV reactivation and YMDD mutation keep good graft function after add on adefovir. Conclusion: The combination of lamivudine and long-term HBIG has effective long term efficiency to prevent the reactivation of HBV after liver transplantation. The low dose HBIG in our series saved the medical cost without perturbing the long term efficiency. New antiviral strategy should be developed for the patients with high risk of resistance to lamivudine.