Figure 1036

Survival of hepatitis B virus (HBV)-infected patients with end-stage renal disease treated with either dialysis or transplantation. Patients infected with HBV (hepatitis B surface antigen [HBsAg] positive) on hemodialysis were matched for age with 22 previously transplanted HBsAg-positive patients. This study shows the reason for concern and investigation as to the safety of transplantation in HBV-infected patients. Although there are other studies showing a significantly decreased survival in patients transplanted with HBV infection, most currently show equivalent survival of over 10 years. The cause of death in the HBV-infected group, however, may more often be from infection and liver failure than from cardiac disease.

The safety of transplantation in HBsAg-positive patients has been debated for over 25 years. Increased mortality, if seen, is usually seen beyond 10 years following transplantation and is often secondary to liver failure or sepsis. The acquisition of hepatitis B infections post-transplant, however, does carry a worse prognosis. Virtually all patients with severe chronic active hepatitis, and 50% to 60% of those with mild chronic active hepatitis on liver biopsy prior to transplantation, will progress to cirrhosis. Patients with chronic persistent hepatitis usually do not show histologic progression over 4 to 5 years of follow-up, although mild lesions do not guarantee preservation of hepatic function over longer periods. The complete natural history of hepatitis B following transplantation is not known, as biopsies have been performed largely in those who have abnormal liver function tests; however, one recent study, that included analyses of all individuals who were HBsAg positive around the time of transplantation, has shown histologic progression in 85.3% of those who were rebiopsied with the development of hepatocellular carcinoma in eight of 35 patients who developed cirrhosis. A key to management of patients who were HBsAg positive following transplantation is to periodically monitor the liver by ultrasound and to perform a serum alpha-fetoprotein level to detect hepatocellular carcinoma at the earliest possible stage. The key to minimizing the effects of hepatitis B infections following transplantation, however, is to administer the hepatitis B vaccine as early as possible in the treatment for end-stage renal disease. It is noted that 60% will develop antihepatitis B titers when vaccinated while on dialysis compared with only 40% of those who have already been transplanted. Co-infection with hepatitis C may result in more aggressive liver disease but so far has not led to a marked decrease in patient survival. Because of the high risk of acute renal failure or rejection with the use of interferon post-transplant, treatment of hepatitis B with interferon following renal transplantation is not advised. Lamivudine or other experimental antihepatitis agents may be used pretransplant for patients with hepatitis B infection. (Figure adapted from Harnett and coworkers. [11]; with permission.)

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