Accepted Article
Received Date : 02-Sep-2014 Revised Date : 02-Dec-2014 Accepted Date : 28-Jan-2015 Article type
: Original Report
Low-dose short-term hepatitis B immunoglobulin with high genetic barrier antivirals: the ideal post-transplant hepatitis B virus prophylaxis? N.S. Choudhary, N. Saraf, S. Saigal, R. Mohanka, A. Rastogi, S. Goja, P.B. Menon, A.S. Soin
N.S. Choudhary, N. Saraf, S. Saigal, R. Mohanka, A. Rastogi, S. Goja, P.B. Menon, A.S. Soin Medanta Liver Institute, Medanta The Medicity, Gurgaon, Haryana, India
Running title: Choudhary et al: HBV prophylaxis after liver transplantation
Correspondence to: Neeraj Saraf, Senior Consultant, Medanta Liver Institute,
Medanta The Medicity, Sector 38, Gurgaon, Haryana, India 122001 Tel: +919899077795 Fax: E-mail: [email protected] This is an Accepted Article that has been peer-reviewed and approved for publication in the Transplant Infectious Disease, but has yet to undergo copy-editing and proof correction. Please cite this article as an “Accepted Article”; doi: 10.1111/tid.12369 This article is protected by copyright. All rights reserved.
Accepted Article
Abstract: Background. Low-dose hepatitis B immunoglobulin (HBIG) and nucleos(t)ides analogues (lamivudine/adefovir) used for the prevention of hepatitis B virus (HBV) recurrence after liver transplantation (LT) are associated with some risk of HBV recurrence and antiviral resistance. Methods. The study cohort included 176 patients (at least >12 months follow-up) with HBV cirrhosis/hepatocellular carcinoma who received secondary prophylaxis with indefinite entecavir/tenofovir after living-donor LT (LDLT). All patients received 10000 IU intravenous HBIG in anhepatic phase followed by 600–1000 IU intramuscularly daily for 7 days, weekly for 3 weeks, and then monthly, to keep antiHBs levels >100 mIU/mL for 1 year. Hepatitis B surface antigen (HBsAg) and HBV DNA were tested 6 monthly. Results. The study cohort is comprised of 157 males, 19 females, mean age 47.9 ± 10.1 years, all HBsAg positive, 35 (19.8%) had HBV DNA >2000 IU/mL before LT. After LT, patients received entecavir (n = 126, 71.5%), tenofovir (n = 20, 11.3%), or a combination of entecavir and tenofovir (n = 30, 17% for 3 months, followed by entecavir alone). During follow-up of 43 (12–117) months, 2 patients (including 1 with non-compliance) had HBV recurrence.
Conclusion. In a large cohort of LDLT recipients for HBV-related liver disease, use of low-dose short-term HBIG with high genetic barrier drugs results in a substantially lower incidence of HBV recurrence, even in high-risk patients.
Key words: HBIG; hepatitis B; HBsAg; HBV DNA; liver transplantation; entecavir; tenofovir
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Hepatitis B-related liver disease is a common indication for liver transplantation (LT) in Asian countries including India. Before the introduction of hepatitis B immunoglobulin (HBIG) to prevent reinfection of the liver graft, hepatitis B patients had poor outcome after LT (80–100% recurrence and poor survival) (1, 2), whereas nowadays, with use of prophylaxis with HBIG and antivirals, survival of these patients after LT is comparable to that with other etiologies of cirrhosis (3). Earlier, Terrault et al. (4) showed significantly less recurrence in the ‘HBIG group’ than in the ‘no HBIG group’ (2-year recurrence rate defined by the reappearance of hepatitis B surface antigen [HBsAg] was 19% in the HBIG group vs. 76% in those without HBIG). Subsequently, various studies using a combination of HBIG and antiviral drugs have shown recurrence rates of around 10% (5–10). Several studies have shown that hepatitis B virus (HBV)
persists at both hepatic and extrahepatic sites after LT, thus long-term prophylaxis is needed (11, 12). In order to prevent HBV recurrence, HBIG prophylaxis should ideally be given lifelong. However, considerable cost is involved in HBIG prophylaxis (4), hence alternative strategies have been applied, including antivirals alone (associated with recurrence and resistance to antivirals or persistence of HBsAg/ HBV DNA) (13–16), and low-dose HBIG with antivirals (lamivudine and adefovir) (6, 7, 17). There is paucity of data on the newer antivirals (high genetic barrier drugs
entecavir or tenofovir) that may yield
better results than
lamivudine/adefovir, as resistance is uncommon with these newer drugs (18–20). The present study focuses on the outcome of patients who received post-transplant prophylaxis with low-dose
short-term intramuscular (IM) HBIG and high genetic barrier antivirals (entecavir or tenofovir).
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Patients and methods Data were prospectively collected on all the patients (among a total of 1206) who underwent living-donor LT (LDLT) for hepatitis B-related cirrhosis from January 2006 to June 2012. The study has been approved by our Institutional Review Board. Among these, 176 patients who received post-transplant prophylaxis with entecavir and/or tenofovir, who survived at least a year, were the study cohort. Those who died (n = 27, mainly because of sepsis) or had follow-up < 12 months were excluded; none of the deaths were a result of hepatitis B recurrence. The following parameters were analyzed: pre-transplant HBV DNA, indication of transplant, antiviral agent used, post-transplant renal function, graft survival, and recurrence of hepatitis B (HBsAg, serum HBV DNA). HBIG was given 10,000 international units (IU) intravenously in the anhepatic phase, then 1000 IU IM daily for 7, days followed by 1000 U IM weekly for next 3 weeks, and then 600–1000 U HBIG IM monthly to keep anti-HBs levels at 100–250 IU/mL for a total duration of 1 year; then HBIG was stopped in all. All patients received oral antiviral drugs (entecavir/tenofovir) in the post-transplant period. HBV recurrence was defined as the detection of HBsAg and/or HBV DNA in the serum during the post-transplant follow-up (done every 6 months or as needed) (17). The primary end point of study was at the time this manuscript was written. Before LT 107 patients were on treatment for hepatitis B, with treatment duration being 6.5 (interquartile range 2–24 months), mainly with entecavir (n = 68). The rest of the patients received antivirals when they came to us for LT work up. All these treatment-naive patients were started on a single antiviral (entecavir or tenofovir) before LT. Patients with HBV DNA >105
IU/mL were started on dual antivirals. In patients for whom LT was not urgent, we waited until HBV DNA was negative. In patients with high HBV DNA, who could not wait too long before LT because of fear of disease progression (hepatocellular carcinoma [HCC]), or who were too
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sick to wait (high Model for End-stage Liver Disease score), entecavir and tenofovir combination therapy was used to bring HBV DNA levels rapidly down to undetectable or as low as possible before LT as the clinical status of the patient would allow (aiming for at least a > 2 log reduction), to decrease the risk of post-transplant HBV recurrence. In these patients, tenofovir was continued for 3 months after LT (after documenting negative HBsAg and HBV DNA), and entecavir was continued indefinitely. All donors were HBsAg negative. HBV DNA was also done for donors who were hepatitis B core antibody positive, and only HBsAg- and HBV DNAnegative donors were accepted for donation. The immunosuppression protocol at our center consisted of calcineurin inhibitors (mainly tacrolimus), mycophenolate, and steroids (tapered over first 3 months). Patients received calcineurin inhibitors lifelong, and mycophenolate was stopped in the majority of patients at 2 years.
Statistical methods Data are presented as mean (standard deviation), median (range), or number and percentage.
Results The study group included 157 men and 19 women, with a mean age of 47.9 ± 10.1 years, with a mean follow-up of 43 (range 12–117) months. None of the patients had co-infection with hepatitis C, hepatitis D, or human immunodeficiency viruses. Preoperative characteristics of the study population are shown in Table 1. All patients tested positive for HBsAg; 76 (43.1%) patients were HBV DNA-positive before LT, with a median DNA value was 977 IU/mL. Before LDLT, 35 (24.2%) patients had HBV DNA >2000 IU. Post transplant, patients received entecavir (n = 126, 71.5%), tenofovir (n = 20, 11.3%), or a combination of entecavir and
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tenofovir (n = 30, 17%) for 3 months, followed by entecavir alone. During follow up, 2 patients became HBsAg positive; both of them had high DNA (> 1 × 107 IU/mL) before LDLT. Of these
2, 1 patient was non-compliant and became positive for HBsAg and serum HBV DNA 12 months after LT. He was treated with tenofovir, in addition to the entecavir that he was already on, and his HBV DNA became negative after 6 months; his viral resistance profile was negative for entecavir and tenofovir. The second patient became HBsAg positive 24 months after LT on entecavir, after which tenofovir was added to his treatment, and he is on follow up. None of the patients on tenofovir had renal impairment during the study period.
Discussion After the early dismal results, introduction of HBIG improved the survival of patients undergoing LT for hepatitis B-related disease (3). HBIG is a polyclonal antibody to HBsAg and is derived from pooled human plasma. The possible mechanisms to prevent reinfection of graft include binding to and neutralizing of circulating virions expressing HBsAg (thus preventing infection of hepatocytes, and perhaps inciting lysis of infected cells; prevention of cell-to-cell hepatocyte infection; and reduction in HBsAg and virion secretion after endocytosis into hepatocytes (21, 22). Initial studies reported the use of high-dose HBIG, but it proved too costly.
Subsequently, with the availability of antivirals, several studies evaluated the combination of lamivudine and low-dose HBIG (6, 7, 23–29). This strategy proved to be cost-effective and reduced the recurrence rate of hepatitis B to 2000 IU/mL). Several studies have been published on use of antivirals alone to prevent hepatitis B
recurrence after LT. In a study using antivirals alone for hepatitis B recurrence prophylaxis, Fung et al. (32) showed better results with entecavir alone or the combination of lamivudine and adefovir, when compared to lamivudine alone (virological relapse at 3 years was 0, 7%, and 17% respectively). In another study by the same group, entecavir alone (without HBIG) was used in 80 patients, and HBsAg was positive in 14% and 9% patients at 1 and 2 years respectively (16). In a study from India of treatment with antivirals without HBIG, 10% and 8% were positive for HBsAg at 1- and 2-year follow-up (18). Although, we do not have a control arm of antivirals
alone, by using short-term HBIG, we achieved a lower rate of recurrence than in the abovementioned studies and in studies using HBIG and low genetic barrier antivirals. Studies using antivirals alone show an HBsAg-positive status in about 10% of recipients at 1 year (16, 18). This is likely from an inactive hepatitis B carrier state; pre-transplant studies have shown that inactive carrier patients are also at risk of development of HCC, even after loss of HBsAg (33).
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Perhaps HBsAg-positive status after LT translates to later development of HCC in these immunocompromised patients, but this is not known at present, as it needs a longer follow-up than that reported in these studies. We believe that achieving complete hepatitis B-negative status (absence of both HBsAg
and HBV DNA) is the ideal state after LT. Another study using entecavir and HBIG with 72 weeks of follow-up had only 2 recurrences (none HBV DNA positive). Our results also show that entecavir or tenofovir can be used in patients even with high HBV DNA before LT, with minimal recurrence and an excellent safety profile. Our policy of using 2 high genetic barrier antivirals before LT to bring DNA levels
rapidly down (in patients with high HBV DNA levels and need of early transplant owing to severity of liver disease or HCC) is recently supported by Lok et al. (34) who demonstrated more rapid fall of HBV DNA levels in the combination group than in either entecavir or tenofovir along groups. Strengths of the present study include a large cohort including a significant number of patients with HBV DNA >2000 IU/mL (representing a high risk of hepatitis B recurrence); use of low-dose HBIG for a definite period (1 year only) thereby decreasing cost; data on tenofovir use in addition to entecavir use; and long follow-up. We believe that use of HBIG with high genetic barrier antivirals is associated with lower recurrence rates, as compared to antivirals alone or HBIG combined with low genetic barrier antivirals.
Acknowledgements: Thanks: The authors thank Mr. Yogesh Saini and Mrs. Rabia (research coordinators).
Funding: None. Conflict of interest: None.
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34.
Lok AS, Trinh H, Carosi G, et al. Efficacy of entecavir with or without tenofovir disoproxil fumarate for nucleos(t)ide-naïve patients with chronic hepatitis B. Gastroenterology 2012; 143: 619–628.e1
Preoperative characteristics of 176 patients Parameter
Mean ± SD or mean (%)
Age in years
47.9 ± 10.1
Gender Male
157 (89.2%)
Female
19 (10.7%)
Hepatocellular carcinoma
40 (22.7%)
CTP
8.8 ± 2.3
MELD
19.7 ± 7.1
HBsAg positive
176 (100%)
Pre-transplant DNA >2000 IU/mL
35 (19.8%)
CTP, Child–Turcotte–Pugh cirrhosis score; MELD, Model for End-stage Liver Disease score; HBsAg, hepatitis B surface antigen. Table 1
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Received Date : 02-Sep-2014 Revised Date : 02-Dec-2014 Accepted Date : 28-Jan-2015 Article type
: Original Report
Low-dose short-term hepatitis B immunoglobulin with high genetic barrier antivirals: the ideal post-transplant hepatitis B virus prophylaxis? N.S. Choudhary, N. Saraf, S. Saigal, R. Mohanka, A. Rastogi, S. Goja, P.B. Menon, A.S. Soin
N.S. Choudhary, N. Saraf, S. Saigal, R. Mohanka, A. Rastogi, S. Goja, P.B. Menon, A.S. Soin Medanta Liver Institute, Medanta The Medicity, Gurgaon, Haryana, India
Running title: Choudhary et al: HBV prophylaxis after liver transplantation
Correspondence to: Neeraj Saraf, Senior Consultant, Medanta Liver Institute,
Medanta The Medicity, Sector 38, Gurgaon, Haryana, India 122001 Tel: +919899077795 Fax: E-mail: [email protected] This is an Accepted Article that has been peer-reviewed and approved for publication in the Transplant Infectious Disease, but has yet to undergo copy-editing and proof correction. Please cite this article as an “Accepted Article”; doi: 10.1111/tid.12369 This article is protected by copyright. All rights reserved.
Accepted Article
Abstract: Background. Low-dose hepatitis B immunoglobulin (HBIG) and nucleos(t)ides analogues (lamivudine/adefovir) used for the prevention of hepatitis B virus (HBV) recurrence after liver transplantation (LT) are associated with some risk of HBV recurrence and antiviral resistance. Methods. The study cohort included 176 patients (at least >12 months follow-up) with HBV cirrhosis/hepatocellular carcinoma who received secondary prophylaxis with indefinite entecavir/tenofovir after living-donor LT (LDLT). All patients received 10000 IU intravenous HBIG in anhepatic phase followed by 600–1000 IU intramuscularly daily for 7 days, weekly for 3 weeks, and then monthly, to keep antiHBs levels >100 mIU/mL for 1 year. Hepatitis B surface antigen (HBsAg) and HBV DNA were tested 6 monthly. Results. The study cohort is comprised of 157 males, 19 females, mean age 47.9 ± 10.1 years, all HBsAg positive, 35 (19.8%) had HBV DNA >2000 IU/mL before LT. After LT, patients received entecavir (n = 126, 71.5%), tenofovir (n = 20, 11.3%), or a combination of entecavir and tenofovir (n = 30, 17% for 3 months, followed by entecavir alone). During follow-up of 43 (12–117) months, 2 patients (including 1 with non-compliance) had HBV recurrence.
Conclusion. In a large cohort of LDLT recipients for HBV-related liver disease, use of low-dose short-term HBIG with high genetic barrier drugs results in a substantially lower incidence of HBV recurrence, even in high-risk patients.
Key words: HBIG; hepatitis B; HBsAg; HBV DNA; liver transplantation; entecavir; tenofovir
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Accepted Article
Hepatitis B-related liver disease is a common indication for liver transplantation (LT) in Asian countries including India. Before the introduction of hepatitis B immunoglobulin (HBIG) to prevent reinfection of the liver graft, hepatitis B patients had poor outcome after LT (80–100% recurrence and poor survival) (1, 2), whereas nowadays, with use of prophylaxis with HBIG and antivirals, survival of these patients after LT is comparable to that with other etiologies of cirrhosis (3). Earlier, Terrault et al. (4) showed significantly less recurrence in the ‘HBIG group’ than in the ‘no HBIG group’ (2-year recurrence rate defined by the reappearance of hepatitis B surface antigen [HBsAg] was 19% in the HBIG group vs. 76% in those without HBIG). Subsequently, various studies using a combination of HBIG and antiviral drugs have shown recurrence rates of around 10% (5–10). Several studies have shown that hepatitis B virus (HBV)
persists at both hepatic and extrahepatic sites after LT, thus long-term prophylaxis is needed (11, 12). In order to prevent HBV recurrence, HBIG prophylaxis should ideally be given lifelong. However, considerable cost is involved in HBIG prophylaxis (4), hence alternative strategies have been applied, including antivirals alone (associated with recurrence and resistance to antivirals or persistence of HBsAg/ HBV DNA) (13–16), and low-dose HBIG with antivirals (lamivudine and adefovir) (6, 7, 17). There is paucity of data on the newer antivirals (high genetic barrier drugs
entecavir or tenofovir) that may yield
better results than
lamivudine/adefovir, as resistance is uncommon with these newer drugs (18–20). The present study focuses on the outcome of patients who received post-transplant prophylaxis with low-dose
short-term intramuscular (IM) HBIG and high genetic barrier antivirals (entecavir or tenofovir).
This article is protected by copyright. All rights reserved.
Accepted Article
Patients and methods Data were prospectively collected on all the patients (among a total of 1206) who underwent living-donor LT (LDLT) for hepatitis B-related cirrhosis from January 2006 to June 2012. The study has been approved by our Institutional Review Board. Among these, 176 patients who received post-transplant prophylaxis with entecavir and/or tenofovir, who survived at least a year, were the study cohort. Those who died (n = 27, mainly because of sepsis) or had follow-up < 12 months were excluded; none of the deaths were a result of hepatitis B recurrence. The following parameters were analyzed: pre-transplant HBV DNA, indication of transplant, antiviral agent used, post-transplant renal function, graft survival, and recurrence of hepatitis B (HBsAg, serum HBV DNA). HBIG was given 10,000 international units (IU) intravenously in the anhepatic phase, then 1000 IU IM daily for 7, days followed by 1000 U IM weekly for next 3 weeks, and then 600–1000 U HBIG IM monthly to keep anti-HBs levels at 100–250 IU/mL for a total duration of 1 year; then HBIG was stopped in all. All patients received oral antiviral drugs (entecavir/tenofovir) in the post-transplant period. HBV recurrence was defined as the detection of HBsAg and/or HBV DNA in the serum during the post-transplant follow-up (done every 6 months or as needed) (17). The primary end point of study was at the time this manuscript was written. Before LT 107 patients were on treatment for hepatitis B, with treatment duration being 6.5 (interquartile range 2–24 months), mainly with entecavir (n = 68). The rest of the patients received antivirals when they came to us for LT work up. All these treatment-naive patients were started on a single antiviral (entecavir or tenofovir) before LT. Patients with HBV DNA >105
IU/mL were started on dual antivirals. In patients for whom LT was not urgent, we waited until HBV DNA was negative. In patients with high HBV DNA, who could not wait too long before LT because of fear of disease progression (hepatocellular carcinoma [HCC]), or who were too
This article is protected by copyright. All rights reserved.
Accepted Article
sick to wait (high Model for End-stage Liver Disease score), entecavir and tenofovir combination therapy was used to bring HBV DNA levels rapidly down to undetectable or as low as possible before LT as the clinical status of the patient would allow (aiming for at least a > 2 log reduction), to decrease the risk of post-transplant HBV recurrence. In these patients, tenofovir was continued for 3 months after LT (after documenting negative HBsAg and HBV DNA), and entecavir was continued indefinitely. All donors were HBsAg negative. HBV DNA was also done for donors who were hepatitis B core antibody positive, and only HBsAg- and HBV DNAnegative donors were accepted for donation. The immunosuppression protocol at our center consisted of calcineurin inhibitors (mainly tacrolimus), mycophenolate, and steroids (tapered over first 3 months). Patients received calcineurin inhibitors lifelong, and mycophenolate was stopped in the majority of patients at 2 years.
Statistical methods Data are presented as mean (standard deviation), median (range), or number and percentage.
Results The study group included 157 men and 19 women, with a mean age of 47.9 ± 10.1 years, with a mean follow-up of 43 (range 12–117) months. None of the patients had co-infection with hepatitis C, hepatitis D, or human immunodeficiency viruses. Preoperative characteristics of the study population are shown in Table 1. All patients tested positive for HBsAg; 76 (43.1%) patients were HBV DNA-positive before LT, with a median DNA value was 977 IU/mL. Before LDLT, 35 (24.2%) patients had HBV DNA >2000 IU. Post transplant, patients received entecavir (n = 126, 71.5%), tenofovir (n = 20, 11.3%), or a combination of entecavir and
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tenofovir (n = 30, 17%) for 3 months, followed by entecavir alone. During follow up, 2 patients became HBsAg positive; both of them had high DNA (> 1 × 107 IU/mL) before LDLT. Of these
2, 1 patient was non-compliant and became positive for HBsAg and serum HBV DNA 12 months after LT. He was treated with tenofovir, in addition to the entecavir that he was already on, and his HBV DNA became negative after 6 months; his viral resistance profile was negative for entecavir and tenofovir. The second patient became HBsAg positive 24 months after LT on entecavir, after which tenofovir was added to his treatment, and he is on follow up. None of the patients on tenofovir had renal impairment during the study period.
Discussion After the early dismal results, introduction of HBIG improved the survival of patients undergoing LT for hepatitis B-related disease (3). HBIG is a polyclonal antibody to HBsAg and is derived from pooled human plasma. The possible mechanisms to prevent reinfection of graft include binding to and neutralizing of circulating virions expressing HBsAg (thus preventing infection of hepatocytes, and perhaps inciting lysis of infected cells; prevention of cell-to-cell hepatocyte infection; and reduction in HBsAg and virion secretion after endocytosis into hepatocytes (21, 22). Initial studies reported the use of high-dose HBIG, but it proved too costly.
Subsequently, with the availability of antivirals, several studies evaluated the combination of lamivudine and low-dose HBIG (6, 7, 23–29). This strategy proved to be cost-effective and reduced the recurrence rate of hepatitis B to 2000 IU/mL). Several studies have been published on use of antivirals alone to prevent hepatitis B
recurrence after LT. In a study using antivirals alone for hepatitis B recurrence prophylaxis, Fung et al. (32) showed better results with entecavir alone or the combination of lamivudine and adefovir, when compared to lamivudine alone (virological relapse at 3 years was 0, 7%, and 17% respectively). In another study by the same group, entecavir alone (without HBIG) was used in 80 patients, and HBsAg was positive in 14% and 9% patients at 1 and 2 years respectively (16). In a study from India of treatment with antivirals without HBIG, 10% and 8% were positive for HBsAg at 1- and 2-year follow-up (18). Although, we do not have a control arm of antivirals
alone, by using short-term HBIG, we achieved a lower rate of recurrence than in the abovementioned studies and in studies using HBIG and low genetic barrier antivirals. Studies using antivirals alone show an HBsAg-positive status in about 10% of recipients at 1 year (16, 18). This is likely from an inactive hepatitis B carrier state; pre-transplant studies have shown that inactive carrier patients are also at risk of development of HCC, even after loss of HBsAg (33).
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Perhaps HBsAg-positive status after LT translates to later development of HCC in these immunocompromised patients, but this is not known at present, as it needs a longer follow-up than that reported in these studies. We believe that achieving complete hepatitis B-negative status (absence of both HBsAg
and HBV DNA) is the ideal state after LT. Another study using entecavir and HBIG with 72 weeks of follow-up had only 2 recurrences (none HBV DNA positive). Our results also show that entecavir or tenofovir can be used in patients even with high HBV DNA before LT, with minimal recurrence and an excellent safety profile. Our policy of using 2 high genetic barrier antivirals before LT to bring DNA levels
rapidly down (in patients with high HBV DNA levels and need of early transplant owing to severity of liver disease or HCC) is recently supported by Lok et al. (34) who demonstrated more rapid fall of HBV DNA levels in the combination group than in either entecavir or tenofovir along groups. Strengths of the present study include a large cohort including a significant number of patients with HBV DNA >2000 IU/mL (representing a high risk of hepatitis B recurrence); use of low-dose HBIG for a definite period (1 year only) thereby decreasing cost; data on tenofovir use in addition to entecavir use; and long follow-up. We believe that use of HBIG with high genetic barrier antivirals is associated with lower recurrence rates, as compared to antivirals alone or HBIG combined with low genetic barrier antivirals.
Acknowledgements: Thanks: The authors thank Mr. Yogesh Saini and Mrs. Rabia (research coordinators).
Funding: None. Conflict of interest: None.
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Preoperative characteristics of 176 patients Parameter
Mean ± SD or mean (%)
Age in years
47.9 ± 10.1
Gender Male
157 (89.2%)
Female
19 (10.7%)
Hepatocellular carcinoma
40 (22.7%)
CTP
8.8 ± 2.3
MELD
19.7 ± 7.1
HBsAg positive
176 (100%)
Pre-transplant DNA >2000 IU/mL
35 (19.8%)
CTP, Child–Turcotte–Pugh cirrhosis score; MELD, Model for End-stage Liver Disease score; HBsAg, hepatitis B surface antigen. Table 1
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