Gregg Kunder

Hepatitis C Positive Grafts may be used in Orthotopic Liver Transplantation: A Matched Analysis

Hepatitis C (HCV)‐positive liver grafts have been increasingly used in patients with decompensated liver disease from HCV because of critical shortage of available organs. Fifty‐nine recipients of HCV‐positive grafts were matched to patients who received HCV‐negative grafts. All recipients were transplanted for HCV liver disease. Matching variables were (1) status, (2) pre‐transplant creatinine, (3) recipient age, (4) donor age, (5) warm ischemia time, and (6) year of transplantation. Both unmatched and matched analyses were performed on patient survival, graft survival, and time to HCV recurrence. There was no significant statistical difference in patient, graft, or HCV recurrence‐free survival between recipients of HCV‐positive and HCV‐negative grafts with matched and unmatched analyses (p > 0.05). The 3‐year estimates of HCV disease‐free survival were 12% (± 9%) and 19% (± 7%) using HCV‐positive and –negative grafts, respectively. The use of HCV‐positive grafts in recipients with HCV does not appear to affect patient survival, graft survival, or HCV recurrence when compared with the use of HCV‐negative grafts. Our results suggest that HCV‐positive grafts can be used in a HCV liver transplant recipient.

Discordance Between ALT Values and Fibrosis in Liver Transplant Recipients Treated with Ribavirin for Recurrent Hepatitis C

Hepatitis C virus (HCV) recurrence is a serious problem after orthotopic liver transplantation (OLT). The role of ribavirin as a single agent to treat recurrent HCV is controversial. Our aim was to evaluate the correlation between alanine aminotransferase (ALT) levels and histological findings in OLT recipients treated with ribavirin monotherapy for recurrent HCV. The mean [± standard error (SE)] age of 11 patients was 50.1 (SE ± 8.6) years. The estimated mean dose and duration of ribavirin treatment (± SE) was 661.5 (± 52.5) mg and 20.4 (± 1.7) months, respectively. Five patients required either dose reduction or erythropoietin. We found a significant decrease of mean (± SE) ALT value from 246 ± 44.8 U/L to 109.4 ± 49.1 U/L (p = 0.002) in patients treated with ribavirin. However, there was also significant worsening of interface activity (p = 0.03) and fibrosis (p = 0.02). No significant association was found between ALT values and (i) stage of hepatic fibrosis, (ii) interface activity, (iii) lobular activity and (iv) HCV RNA values. Our results suggest that HCV disease can progress despite a significant decrease in ALT values. ALT values are inadequate markers of the ribavirin monotherapy and can lead to erroneous conclusions of efficacy.

IM hepatitis B immune globulin (HBIG) is as efficacious as the IV form in the maintenance of HBSAB titers and prevention of hepatitis B (HBV) recurrence in post orthotopic liver transplant (OLT) patients

Introduction: Long-term immunoprophylaxis with HBIG monotherapy reduces HBV recurrence in OLT patients, although the IV form has a number of limitations including expense and a HBV recurrence rate of approximately 20%. Combination prophylaxis with HBIG and lamivudine reduces recurrence rates further although the disadvantages of IV HBIG remain. The cost of IV HBIG has become prohibitive and thus we now report the use of 1M HBIG in maintaining adequate HBsAb titers. Methods: This was a retrospective study evaluating 49 patients transplanted between 6/93 and 8/99. Patients were treated with lamivudine, 150 mg po qd, and HBIG, 10,000 ru IV, in standard protocol (one dose intraoperatively, qd for six days, and then qmo indefinately) and then changed to 1M given as 5 ml qmo. HBsAb, HBsAg, and HBV DNA were checked monthly. Patients were changed back to IV if HBsAb levels dropped below 100 IV. All patients were continued on lamivudine. Two patients died of unrelated causes. Mean follow-up for the remaining 47 patients was 200 days (range, 40 to 353). Results: 38147 (81%) patients treated with 1M HBIG were able to maintain adequate HBsAb titers. Nine patients (19%) required intermittent IV administration for low titers or poor tolerance. No patients had recurrence of HBsAg or HBV DNA. Conclusions: 81% of patients tolerated conversion to 1M administration of HBIG with adequate HBsAb titers and without recurrence of HBV. The potential cost savings and ease of administration make 1M HBIG a viable alternative in OLT patients, Longterm follow up will determine whether 1M HBIG provides durable protection against HBV recurrence, although our initial experience suggests that excellent protection against HBV recurrence is possible. 1155