Real-time measurement of anti-HBs level and donor-specific transfusion via portal vein may reduce amount of HBIG after living related liver transplantation.

Abstract

TO THE EDITOR: The use of high doses of i.v. hepatitis B immune globulin (HBIG) after liver transplantation has reduced hepatitis B virus (HBV) recurrence and improved survival (1, 2, 3). The typical prophylactic regimen consists of high doses of i.v. HBIG (10,000 IU) during the nonhepatic phase, and subsequent doses of i.v. HBIG of 10,000 IU/day for the 1st wk and 10,000 IU/wk up to the 1st month. It is more effective to maintain an anti-hepatitis B surface (anti-HBs) titer above 500 U/ml for prevention of recurrence of HBV (3). Although the beneficial effect of long term HBIG administration has been widely accepted, the required expense for this therapy amounts to $27,000 for 1 wk, thereby placing a considerable financial burden on the patients. We have been involved with two cases of living related liver transplantation (LRLT) in HBV cirrhosis. In these cases, 100 mg/day of lamivudine was administered 4 wk before LRLT and 10,000 IU of HBIG was administered 2 consecutive days after LRLT. After this, the amount of HBIG was determined based on the real-time measurement of anti-HBs titer using lumipuls (Fuji Rebio, Tokyo, Japan), which takes only 1 h. The first patient took 2,000 U of HBIG per 4 days for maintaining over 500 U/ml and then 2,000 U/month was given 2 months after LRLT. One year after transplantation, HBIG was stopped and HBV vaccination (4) was administered. A second patient also underwent the same therapy regimen as the first; however, HBIG treatment was stopped in this patient after 5 months so as to be able to maintain anti-HBV titer above 200 U/ml without the administration of HBIG. Real-time measurement of anti-HBs titer might obviate HBIG treatment, which could spare the patient the cost of $7,000 in the 1st operative wk. We also have performed donor-specific transfusion via the portal vein after LRLT (5, 6). In these patients, steroid therapy was withdrawn within 1 month and FK506 rapidly reduced to 1 mg/day, and 0.5 mg/14 days by 4 months after LRLT. The rapid reduction of immunosuppressants might lead to success in the reduction of HBIG and the vaccination of HBV. In conclusion, i.m. HBIG combined with lamivudine or low dose HBIG combined with lamivudine have been demonstrated (7, 8); however, our clinical trial by intraportal donor-specific transfusion and further understanding of the immunological mechanism in LRLT might contribute to the reduction of HBIG and prevent the recurrence of HBV.