Prevention of Recurrent Hepatitis B

After Liver Transplantation

Chung-Mau Lo
Chin Lan Hong Professor of Hepatobiliary Surgery
Department of Surgery
The University of Hong Kong Medical Center
Queen Mary Hospital
Hong Kong, China
LIVER TRANSPLANTATION FOR HBV
Monoprophylaxis

Perrillo et al Hepatology 2001

LIVER TRANSPLANTATION FOR HBV
Combination of Lamivudine + HBIG prophylaxis
• Different regimens:
• HBIG followed by lamivudine
• Lamivudine followed by HBIG
• Low dose, intramuscular HBIG
• Recurrence rate of 0 to 18%
• Disadvantages
– ? Life long
– Cost (US$ 1,700 per 10,000 u in Hong Kong)
– Adverse effects of HBIg
LIVER TRANSPLANTATION FOR HBV
Cost-effective Prophylaxis

Markov model for cost-effectiveness analysis

LIVER TRANSPLANTATION FOR HBV
Cost-effective Prophylaxis

Dan et al Liver Transplantation 2005

 LIVER TRANSPLANTATION FOR HBV
Cost-effective Prophylaxis

US$50,000/QALY

US$ 6,000/yr Dan et al Liver Transplantation 2005

LIVER TRANSPLANTATION FOR HBV
HBsAg Carrier Rate
GPD per capita 2000

>$15,000
Hong Kong Kuwait Taiwan
Israel Singapore UAE
Japan S. Korea
$10,001 to 15,000
Macau Saudi Arabia
Oman
$3,001 to 10,000
Indonesia Malaysia Thailand
Iran Sri Lanka
$1,000 to 3,000
Bangladesh Iraq Pakistan
Burma Laos Philippines
China Mongolia Vietnam
India Nepal
<$1,000
Afghanistan Cambodia N. Korea
LIVER TRANSPLANTATION IN HONG KONG
Disease Indication: Overall
polycystic disease

PBC Wilson 1%
2% 2% others
retransplant 10%
3%
biliary atresia
8%

FHF HBV
8% 61%
HCV
5%

Hepatocellular carcinoma, 90 (19%)

LIVER TRANSPLANTATION FOR HBV
Nucleoside/Nucleotide Analogue-Based Prophylaxis
On list
On lamivudine Not on lamivudine

Yes Monitor for mutant* No

Add-on adefovir prophylaxis Lamivudine prophylaxis

OLT OLT

Monitor for mutant* Yes Monitor for mutant* No

* 3-monthly HBVDNA by Amplicor qPCR
and sequencing for mutants Add-on adefovir Lamivudine
LIVER TRANSPLANTATION FOR HBV
Prophylaxis (1995 to 2006)
HBsAg+
324

Pre-OLT Pre-OLT
YMDD mutant no YMDD mutant
33 (10.2%) 290
Not recognised
1

Add-on adefovir Lamivudine

33 291
PRE-TRANSPLANT YMDD MUTANT
Add-on Adefovir Prophylaxis

100
93% 92% 92%
90
93%
Probility of survival (%)

80 88% 84%
70
60
50
pre-OLT mutant (n=33) no mutant (n=290)
40
30
20
10
0
0 6 12 18 24 30 36 42 48 54 60
Time (months)
LIVER TRANSPLANTATION FOR HBV
Lamivudine prophylaxis
Lamivudine prophylaxis
290
YMDD mutant no YMDD mutant
32 (11.1%) 258

Add-on Adefovir 1 Graft survival

0.9
0.8 91.9% 84.6% 79.5%
0.7
FCH 0.6
survival
0.5
0.4
0.3
median FU 38 (1-135) months
Alive Retransplantation 0.2
0.1
24 2 (<1%) 0
Died 0 6 12 18 24 30 36 42 48 54 60
Time (months)
6 (recurrent HCC, 5)
LIVER TRANSPLANATION FOR HBV
Lamivudine Prophylaxis

100 100% 91%

90 91% 84%
Probility of survival (%)

87%
80
78%
70
60
50
with mutant (n=32) without mutant (n=258)
40
30
20
10
0
0 6 12 18 24 30 36 42 48 54 60
Time (months)
LIVER TRANSPLANTATION FOR HBV
YMDD Mutant Rate
100

80
Probability of YMDD mutant(%)

60

40

20
12% 14%
10% 10%
4%
0
0 6 12 18 24 30 36 42 48 54 60
Time (months)
Lo et al Am J Transplantation 2005
LIVER TRANSPLANTATION FOR HBV
Genotype and Lamivudine Resistance
0.3
Probability of lamivudine resistance

21%
0.2
Genotype C

0.1 P=0.017

Genotype B 4%

0
0 6 12 18 24 30 36 42

No. at risk Time (months)

Genotype B 43 39 37 31 23 20 17 14
Genotype C 74 66 56 43 35 27 20 15

Lo et al Am J Transplantation 2005
LIVER TRANSPLANTATION FOR HBV
Viral Factors and Lamivudine Resistance
Recurrence rate p value
1-year 2-year 3-year
HBV genotype B 0% 0% 4% 0.017
C 12% 18% 21%
Precore variant Negative 10% 17% 20% 0.231
Positive 6% 11% 11%
Core promoter variant Negative 6% 11% 11% 0.552
Positive 9% 13% 18%
HBeAg (on listing) Negative 9% 11% 14% 0.946
Positive 6% 12% 17%
HBeAg (at OLT) Negative 8% 11% 14% 0.745
Positive 8% 12% 18%
HBV DNA (on listing) Negative 6% 8% 12% 0.333
Positive 9% 14% 18%
HBV DNA (at OLT) Negative 9% 14% 16% 0.360
Positive 4% 4% 14%
Lo et al Am J Transplantation 2005
LIVER TRANSPLANTATION FOR HBV
Active Immunization- to Replace HBIG
Sanchez-Fueyo Angelico Bienzle
(Barcelona) (Rome) (Berlin)
Number 22 17 20
Pre-OLT HBVDNA+ve 0 0 0
OLT to vaccination (mth) 33 (18-76) 48 (25-85) 78 (24-156)
HBIG before vaccination Yes Yes Yes
HBIG during vaccination No No Yes
Seroconversion
>10 IU/L (%) 63.6 17.6 /
>100 IU/L (%) 23.5 11.8 /
>500 IU/L (%) 9.1 5.9 80
Max anti-HBs titer (IU/L) 47 (10-1,000) 258 (10-601) 25,344 (1255-83121)
Follow up after vaccination (mth) 41 (31-85) 66 (25-88) 13.5 (6-22)
LIVER TRANSPLANTATION FOR HBV
Active Immunization- In Addition to Lamivudine
52 patients on lamivudine prophylaxis 412 (370-2040) days post-OLT
1000
Engerix Engerix
40ug IMI 40ug IMI
anti-HBs titer (mIU/mL)

100

Response rate 7.7%

10

1
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
time (months)
Lo et al J Hepatology 2005
LIVER TRANSPLANTATION FOR HBV
Active Immunization- Pre-S containing Vaccine
20 patients on lamivudine prophylaxis 570 (379-2160) days post-OLT
Sci-B-Vac Sci-B-Vac
1000 40ug IMI 40ug IMI
anti-HBs titer (mIU/mL)

Response rate 50%

100

10

1
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
time (months)Lo et al Am J Transplantation (in press)
LIVER TRANSPLANTATION FOR HBV
Active Immunization- Pre-S containing Vaccine
Responder Non-responder
(n=10) (n=10)
Male gender 8 7
Age in years, median (range) 47.5 (36-57) 54(35-60)*
Age < 50 years 7 1#
HBVDNA positive on listing 1 5
at transplantation 2 2
Disease indication cirrhosis 8 10
cirrhosis with acute flare 2 0
Donor anti-HBs+ 7 6
Living donor graft 7 6
Interval since transplantation 1 – 3 years 6 7
*P = 0.05
#P = 0.02
> 3 years 4 3

Lo et al Am J Transplantation (in press)

LIVER TRANSPLANTATION FOR HBV
Active Immunization- Pre-S containing Vaccine
•Patients (n=14)
pre-transplant HBV non-replicative
on lamivudine+HBIG without recurrence
14 months (12 to 50 months) after liver transplant
•Vaccination protocol
pre-S containing vaccine (Genhavac B Pasteur)
double course of double dose (40ug) IM injection
1 month after HBIG discontinuation
•Results
only 1 patient responded (7%)
anti-HBs titer of 37 IU/L
Karasu et al J Viral Hepatitis 2005
LIVER TRANSPLANTATION FOR HBV
Adoptive Immunity Transfer
21 of 50 patients developed anti-HBs after liver transplantation
Time to develop: 8 (1-43) days
100000 Peak titer no. median (range)
<100 10 37 (12-84)
anti-HBs titer (mIU/mL)

10000 100-1,000 5 252 (101-281)

>1,000 6 8,081 (1,000-121,000)
1000

100

10

1
1 7 14 30 60 90 120 150 180 210 240 270 300 330 360
post-transplant (days) Time to disappear: 207 (24-414) days
Lo et al Hepatology 2003
LIVER TRANSPLANTATION FOR HBV
Adoptive Immunity Transfer

Odd ratio 95% CI P-value

HBV immune donor 18.9 3.2-112.4 0.001

Lo et al Hepatology 2003
DONOR-DERIVED HBV IMMUNITY
HBV-specific Lymphocytes in Liver Graft

Anti-HBs secreting B cell HBsAg specific IFN-secreting T cell HBcAg specific IFN-secreting T cell
2.7/10E6 lymphocytes 4.8/10E6 lymphocytes 4.8/10E6 lymphocytes

ELISPOT assay
Luo et al Liver Transplantation 2006
DONOR-DERIVED HBV IMMUNITY
Intragraft HBV-specific Lymphocytes HBsAg-specific T cells
12

10
Anti-HBs-secreting B cells

SFC/106 intrahepatic lymphocytes

6 8

5 anti-HBs anti-HBc
SFC/106 intrahepatic lymphocytes

Group 1 (22) + +
2

4 Group 2 (10) + -
Group 3 (2) - + 0
Group 1 Group 2 Group3 Group 4

3 Group 4 (7) - - 10
HBcAg-specific T cells

SFC/106 intrahepatic lymphocytes

8
2
6

1
4

0 2

Group 1 Group 2 Group 3 Group 4

0

Group 1 Group 2 Group 3 Group 4

Luo et al Liver Transplantation 2006

DONOR-DERIVED HBV IMMUNITY
Anti-HBs Seroconversion and Intragraft HBV-specific Lymphocytes
HBcAg-specific T cells
10
HBsAg-specific T cells
12 P = 0.082

SFC/106 intrahepatic lymphocytes

8

P < 0.001 6

10
SFC/106 intrahepatic lymphocytes

2
8
0
with anti-HBs production without anti-HBs production

6 Anti-HBs-secreting B cells
6

SFC/106 intrahepatic lymphocytes

4
4 P = 0.088
3
2
2

1
0
with anti-HBs production without anti-HBs production 0
with anti-HBs production without anti-HBs production

Luo et al Liver Transplantation 2006

LIVER TRANSPLANTATION FOR HBV
T-cell Proliferation Response to Mitogen and Recall Antigen
Serial monitoring in 54 patients on lamivudine prophylaxis
a b
140 PHA 14 Tetanus Toxoid
*

Stimulation Index (median + interquartile range)

Stimulation Index (median + interquartile range)

120 12

100 10

80 8

60 6

40 4

20 2

0 0
Day 0 Day 7 Day 14 Day 21 Day 28 Day 90 Day 180 Day 360 Day 0 Day 7 Day 14 Day 21 Day 28 Day 90 Day 180 Day 360
Time after Liver Transplantation Time after Liver Transplantation
 LIVER TRANSPLANTATION FOR HBV
HBV-specific T cell Response
Serial monitoring in 54 patients on lamivudine prophylaxis
10000 16

Number of IFNγ-secreting T cells/2 × 105 PBMC

14

1000 12
Serum anti-HBs titer (mIU/ml)

10

(mean + SD)
100 8

10 4

1 0
Day 0 Day 7 Day 14 Day 21 Day 28 Day 90 Day 180 Day 360 Day 0 Day 7 Day 14 Day 21 Day 28 Day 90 Day 180 Day 360
Time after transplantation Time after Liver Transplantation
LIVER TRANSPLANTATION FOR HBV
HBV-specific T cell Response
Serial monitoring in 54 patients on lamivudine prophylaxis
HBcAg-specific IFN-γ Response
28 Serial
*
monitoring in 54 patients on lamivudinewithout
prophylaxis
anti-HBs response
26
with anti-HBs response
Number of IFNγ-secreting T cells/2× 105 PBMC

24

22 *
(median + interquartile range)

20
*

18
* *
16 * *
*
14

12

10

0
Day 0 Day 7 Day 14 Day 21 Day 28 Day 90 Day 180 Day 360
*P < 0.05 by Mann-Whitney U test Time after transplantation
POST-TRANSPLANT HBV-SPECIFIC IMMUNITY
Independent Predictive Factors
Recipients’ pre-transplant HBV-specific T cell Donors’ HBV-specific T cell immunity
Serial monitoring in 54 patients on lamivudine prophylaxis
immunity

Odd ratio 95% confidence P value Odd ratio 95% confidence P value
interval interval

Anti-HBs 7.1 1.2 to 41.1 0.030 13.5 2.5 to 73.5 0.003

T cell
response
Day 7 Non-computable Non-computable 0.998 11.096 1.144 to 107.574 0.038

Day 14 Non-computable Non-computable 0.998 20.776 1.952 to 221.183 0.012

Day 21 15.848 2.601 to 96.562 0.003 6.387 1.135 to 35.928 0.035

Day 28 48.378 5.035 to 464.814 0.001 11.034 1.532 to 79.482 0.017

Day 90 10.908 2.358 to 50.462 0.002 4.604 0.892 to 23.776 0.068

Day 180 6.372 1.242 to 32.708 0.026 9.192 1.690 to 50.010 0.010

Day 360 Non-computable Non-computable 0.998 9.000 0.691 to 117.254 0.093

LIVER TRANSPLANTATION FOR HBV
Conclusions
• Lamivudine prophylaxis with adefovir rescue is highly
effective in preventing recurrent hepatitis B with
excellent graft survival and is most cost-effective
• There is adoptive transfer of both humoral and cellular
immunity through liver transplantation which may
represent the interplay between donor’s and recipient’s
immunocompetent cells
• Restoration of host immunity to hepatitis B may
provide the ultimate solution for long term recurrence-
free and medication-free survival
PRE-TRANSPLANT YMDD MUTANT
Adefovir Prophylaxis
250
Creatinine clearance (mL/min)

200

150

100

50

0
pre-lamivudine pre-adefovir pre-transplant last follow-up

Lo et al Liver Transplantation 2005

LIVER TRANSPLANTATION FOR HBV
YMDD Mutant Rate
100

80
Probability of YMDD mutant(%)

60

40

20
12% 14%
10% 10%
4%
0
0 6 12 18 24 30 36 42 48 54 60
Time (months)
Lo et al Am J Transplantation 2005
DONOR-DERIVED HBV IMMUNITY
Booster Pre-S Containing Vaccine in Living donor

10000 25
booster vaccine
anti-HBs

anti-HBs secreting B cell (/10E6 PBMC)

20
1000
anti-HBs titer (mIU/mL)

Donor anti-HBs secreting B cell

15
anti-HBs
100

10

10
5
Recipient

anti-HBs secreting B cell

1 0
-1 0 1 2 3 4 5
Time (weeks)
LIVER TRANSPLANTATION FOR HBV
Prophylaxis
• Immunotherapy
– Passive immunoprophylaxis (HBIg)
– Interferon
– Active immunisation
– Adoptive immunity transfer
• Nucleoside analogue
– Lamivudine
– adefovir
– famciclovir
– ganciclovir
– entecavir
– lobucavir
– emtricitabine
LIVER TRANSPLANTATION FOR HBV
Prophylaxis

• HBIg prophylaxis (Terrault et al, Hepatology 1996)

– high cost, parenteral administration, toxicity, s-mutant
• Lamivudine prophylaxis (Grellier et al, Lancet 1996)
– drug resistance due to viral mutant
• Lamivudine + HBIg (Markowitz et al, Hepatology 1998)
– effective
– disadvantages of HBIg
LIVER TRANSPLANTATION FOR HBV
Passive Immunoprophylaxis
• Intravenous HBIG
• Target anti-HBs:
– >100 IU/L (non-replicative)
– >500 IU/L (replicative)
• Recurrence rate:
– 0 to 15% (non-replicative)
– 16-35% (replicative)
• Disadvanges:
• Recurrence due to escape mutants
• High cost
• Parenteral administration
• Toxicity
LIVER TRANSPLANTATION FOR HBV
Improving HBV Prophylaxis
How: Additional prophylaxis
 Other anti-viral agents
• Adefovir
• Entecavir
 Restoration of host immunity
•Active immunisation
•Adoptive immunity transfer
When: Selective
 Pre-OLT escape mutants
 Other high-risk patients
LIVER TRANSPLANTATION FOR HBV
Recurrence
100
HBV DNA+ve
80
Risk of recurrence (%)

HBeAg+ve HBV DNA-ve

60

HBeAg -ve HBV DNA-ve

40

20

0
0 12 24 36 48 60
Months
Samuel et al, New Engl J Med 1993
LIVER TRANSPLANTATION FOR HBV
Retransplantation for Fibrosing Cholestatic Hepatitis
1200
CYC, M/37 1.00E+11

1.00E+10
1000
1.00E+09
YIDD

HBV DNA (copies/mL)

1.00E+08
800
ALT/total bilirubin

1.00E+07
ALT (IU/L)
600 total bilirubin (umol/L) 1.00E+06
HBV DNA 1.00E+05
400
1.00E+04

1.00E+03
200
1.00E+02

0 May 1999
1.00E+01
May 1998
Sep 1997

Nov 1998
Aug 1997

Oct 1997
Nov 1997

Feb 1999
Dec 1997

Feb 1998

Sep 1998

Aug 1999

Nov 1999
Aug 1998

Oct 1998

Oct 1999

Dec 1999
Mar 1999

Sep 1999
Mar 1998
Apr 1998

Apr 1999
Dec 1998
Jun 1998

Jul 1999

Jan 2000
Jul 1998

Jan 1999
Jan 1998

Jun 1999

Lo et al Liver Transplantation 2004

PRE-TRANSPLANT YMDD MUTANT
Adefovir Prophylaxis
No. of patients 16
M:F 15:1
Age (yr) 48 (31-66)
Lamivudine pre-OLT (days) 738 (400-1799)
HBeAg+ 11
HBVDNA >10,000 copies/ml 14
Mutant
rt M204I 13
rt M204V 2
rt M204I and rt M204V 1

Lo et al Liver Transplantation 2005

LIVER TRANSPLANTATION FOR HBV
Primary Lamivudine Prophylaxis

No. of patients 265

M:F 225:40
Age (yr) 47 ± 9 (17-68)
HBeAg+ 83
HBVDNA (bDNA)+ 77
Lamivudine pre-OLT (days) 137 ± 373 (0-4000)
Liver graft
cadaver 87
living 178