Int J Clin Lab Res 22:211-215, 1992
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Orthotopic liver transplantation for chronic viral hepatitis: an overview A. Smedile and M. Rizzetto* Division of Gastroenterology, Molinette Hospital and * Institute of Internal Medicine, University of Turin, Corso Bramante 88, 1-10126 Turin, Italy
Summary. The aim of this review is to discuss the problem of orthotopic liver transplantation in patients suffering from chronic viral liver disease due to hepatitis B, C and D viruses. The decision to operate these patients is often controversial, as the risk of a recurrence of viral infection is very high and reinfection may be severe enough to require a second or even multiple grafts. However, the quality of life and the survival rate improve after transplantation in chronic viral hepatitis patients.
for patients with end-stage organ failure. It is only in the 1990s, therefore, that surgeons and hepatologists have begun to reanalyze their cumulative data on the basis of the original liver infection of the patient, in order to identify factors that influence the outcome of the graft in the long term.
Chronic hepatitis B and liver transplantation Key words: Orthotopic liver transplantation - Reinfection - Chronic hepatitis
Brief history of orthotopic liver transplantation A brief outline of the short history of orthotopic liver transplantation (OLT) will help to understand why the original liver infection of the patient has only become such an important issue in the last few years. Each new step in the history of OLT has been characterized by a major obstacle which has had to be overcome, using the best means available, before the next step can be taken. In the late 1960s and the 1970s the greatest problem for surgeons and hepatologists was the limitations imposed by the surgical techniques of the day. Few patients survived surgergy and the few that did were not enough to counterbalance the high mortality rate. In the late 1970s the survival rate ( 6 0 - 7 0 % at 5 years) at last outweighed the mortality rate. At this point attention focused on the question of immunosuppression and its optimal management in cases of acute and chronic rejection. The introduction of cyclosporin A in 1980 was the real breakthrough, not only for liver transplantation but also for all organ transplants. Cyclosporin A may indeed be considered the true promoter of OLT as a therapeutic procedure Correspondence to: M. Rizzetto
In the initial years of liver transplantation it was difficult to draw a clear picture of patients transplanted for viral cirrhosis type B because of the lack of serological data. Patients were generally classified as having hepatitis B virus (HBV)-related or post-necrotic cirrhosis [27]. Subgrouping into HBsAg positive and HBsAg negative, or as having, or not, markers of past HBV infection, showed clearly that the presence of HBV was a risk factor for reinfection of the graft and for the reappearance of liver disease with a worse long-term outcome. Today the risk of reinfection in candidates with active HBV infections is almost 9 0 - 1 0 0 % in nearly all series. and its appearance may be detected at various intervals after surgery [1]. Many problems still remain unresolved in the management of these patients. We will analyze the limitations that have become apparent from experience in this particular category of recipients and discuss the role of HBV replicative status before liver transplant, and its significance given the improvement in tests for HBV gehome detection. We will also examine the clinical course of HBV patients transplanted for fulminant hepatitis B (FH). Both patients with liver failure resulting from a long-lasting chronic liver disease and previously healthy individuals with an acute HBV infection with a potentially fatal course (FH) are candidates for OLT. The final point to be analyzed and discussed is what measures of prophylaxis and therapy should be recommended in order to prevent reinfection of the graft. Particular attention will be devoted to protocols being studied at the moment.
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Influence of H B V replication on the recurrence of infection in the graft The subtype of chronic hepatitis B in the recipient plays a major role in the recurrence of infection. An analysis of early studies on HBsAg positive disease showed that the replicative status of HBV with the expression of the hepatitis B e antigen (HBeAg) was associated with increased morbidity and mortality in many series [7, 19, 23]. Testing for the HBe/anti-HBe antibody system was used initially to separate carriers of HBsAg with high levels of viremia (HBeAg positive), from those with lower replication (anti-HBe positive). This division was thought to be relatively accurate until the HBV DNA assay was introduced for testing viral replication in serum and liver [3], By measuring levels of DNA at a concentration of a pg/ng per ml, it was possible to reveal HBV sequences even in anti-HBe positive carriers [4]. In a recent study performed at Villejuif, Paris, it was demonstrated that patients who were HBV DNA positive prior to liver transplant had a much greater risk of HBsAg recurrence than patients who where HBV DNA negative (96% vs 29%) at 2 years [26]. A similar experience has been reported by the Pittsburgh group, who have reexamined 51 HBsAg positive patients. Recurrence of HBV in the new liver was the leading cause of mortality occurring after 3 months and was also implicated in 11 (73%) of 15 deaths that occurred during or soon after the operation. Moreover, HBV reinfection was the sole reason for multiple retransplantation in this group [29]. In our series of seven patients transplanted for HBV cirrhosis, six were reinfected within 2 years; all six were anti-HBe positive and all were HBV DNA negative by dot-blot hybridization assay. Recurrence of liver disease in the graft was the rule with an episode of acute hepatitis leading to chronic hepatitis and cirrhosis. The course of recurrent hepatitis to cirrhosis was often more rapid than natural infection (6 months to 1 year). One patient received a second liver transplant for graft failure less than I year after the first graft. Such findings give new insights into the mechanisms used by HBV to cause cellular damage in the graft. For instance, the immunosuppression given to the patient seems to contradict the theory of immunological damage, while it appears that the virus in itself can be pathogenic [8]. A peculiar histological pattern of disease in some patients with recurrent HBV infection was identified in the Cambridge King's College Hospital series. This form, termed fibrosing cholestatic hepatitis (FCH), was associated with rapidly progressive graft dysfunction. The pattern of cell damage described as FCH was characterized by signs of cholestasis and periportal fibrosis; more discriminatory was the presence of abundant tissue HBsAg staining in the allografts [10]. An explanation for these findings was an overexpression of HBsAg proteins with accumulation of the product in the hepatocytes. These pathological features were supported by another transplantation group [14]. By using the in situ hybridization technique with single-stranded probes, this group was able to discriminate between HBV DNA and HBV RNA strands. They found increased staining for HBV RNA
only in livers from recipients with FCH [14]. The only experimental model in which there was overexpression of HBsAg with damage to the hepatocytes was the transgenic mouse model developed by Chisari and coworkers [9]. In this model the overproduction of surface antigen caused an overload of surface proteins with a direct cytotoxic effect. This mimicked the damage caused by metabolic liver disorders. Results in fulminant hepatitis B Viral hepatitis is the most common cause of acute liver failure worldwide. Liver transplants have changed the poor prognosis of FH dramatically. Before the use of liver transplantation, the mortality rate of patients suffering from FH was almost 90%, although those few who survived the virus attack did well, showing serological markers of HBV clearance [2]. Using OLT as the primary therapeutic option for FH has resulted in 1-year survival rates of 5 0 - 7 0 % in many series published in Europe and North America [27]. More important, recurrence o f HBV infection at medium- and long-term follow-up has been negligible (0/17 at 2 years, Villejuif; 1/8 at 4 years, Pittsburgh). In this context, it appears that the prior HBV replicative status does not influence the rate of recurrence in the graft, even though the majority of the recipients were positive for HBV DNA in pretransplant sera. An explanation for this finding might lie in the massive necrosis of infected hepatocytes and the early elimination of viremia which is characteristic of FH. During the fulminant course, serological markers of HBV infection are usually not found, with the exception of early indicators such as high titers of IgM anti-HBc or HBV DNA, using the PCR assay [12]. By contrast, patients with chronic HBV infection and stable viremia have a higher risk of reinfection. A recently recognized virologic aspect concerns mutations appearing in the precore region. The emergence of these mutants may explain severe outbreaks of acute hepatitis in Israel and Japan [13, 20]. Transplantation, however, may have a more favorable outcome when mutant strains of HBV are involved, presumably due to a selection of mutated virions that are less infectious than the wild-type virus. Patients affected by anti-HBe positive/HBV DNA positive chronic hepatitis often show a point mutation at nucleotide 1896 which makes the core genome unable to synthesize the e protein by producing a stop codon [5]. The appearance of specific mutations in nucleotide sequences belonging to regulatory genes may interfere with the production of viral antigens that are expressed in the hepatocyte membranes as targets for the immune system. Measures to prevent H B V recurrence Two different approaches were adopted to prevent HBV recurrence in the graft. The first measure was based on the use of hyperimmunoglobulin anti-HBs (HBIg), given at liver transplantation and maintained for days or weeks, according to the different protocols. The purpose was the neutralization of any HBV particles that had
A. Smedile and M. Rizzetto: Liver transplantation for chronic viral hepatitis been passively transferred during surgery. At the beginning it was thought that this strategy might be effective in the short term. However, when the administration of HBIg was stopped, reinfection took place at a rate similar to that in the unprotected patients [15]. The combination of HBIg with active immunization using recommended doses of HBV vaccine did not afford better results [16]. A successful strategy has been reported by the Hanover transplantation group, using prolonged passive immunoprophylaxis [17]. The protocol was applied to a group of 23 HBsAg positive recipients. Policlonal HBIg was given at a dose of 10000 IU during the anhepatic phase and for the first 8 days following transplantation. The antibody titer was kept at a level of 100 UI for 6 months in I1 patients and for t2 monts in 12 patients. The outcome in treated patients was compared with the outcome in an original group of 11 patients who received HBIg in the anhepatic phase only or not at all. Recurrence of HBV invariably affected the control group, while reinfection did not occur in over 80% of the recipients under HBIg prophylaxis. The outcome was even better for those candidates who were negative for HBV DNA in pretransplant serum samples. Unfortunately, this promising solution can be very expensive if the patients have to be maintained under immunoprophylaxis indefinitely. There are commercially available preparations of monoclonal immunoglobulins which are 5000 times more concentrated; however, they also represent no more than a temporary solution. The real problem lies in the systemic spread of viral particles. HBV D N A replicative species can be detected in extrahepatic tissues such as spleen, pancreas, kidneys and mononuctear cells [30]. These organs act as a reservoir; HBV particles can be harbored in them for a long time and then be reactivated under favorable conditions. The second approach to the prevention of HBV recurrence in the allograft was based on attempts to treat patients with chronic hepatitis B. One of the first studies used preoperative interferon therapy [23]. This study administered an 8-day course of interferon before transplantation and 3 months of interferon therapy after transplantation. However, viremia and liver disease appeared postoperatively. Other trials of combined antiviral therapy (ARA-AMP) and OLT have all resulted in allograft reinfection [11]. These discouraging results have stimulated new measures. One proposal is the administration of the antiviral agent A R A - A M P labeled with albumin before OLT, to abate levels of HBV viremia. Direct delivery of this targeted compound to the hepatocytes has successfully reduced viral replication in the woodchuk model [22]. However, courses of low-dosage interferon before surgery in severely ill patients have sometimes acutely decompensated the patients, necessitating OLT as an emergency procedure.
HDV and liver transplantation The experience with cirrhosis due to hepatitis D virus (HDV) requiring liver transplantation has been generally
213
favorable. The reinfection rate after transplantation ranges from 57 to 77%, with good clinical outcome in 50% of cases. The pretransplant HDV replication status appears not to affect the rate of reinfection. In recipients who were reinfected 3 - 6 months after OLT, the infection ran a course similar to that of natural infection, reproducing a typical pattern of coinfection. Some patients were infected very early in the absence of demonstrable HBV infection, as shown by the presence of delta antigen in the hepatocytes and sporadic positivity to HDV RNA in serum and by the absence of HBV markers. The recrudescence of hepatitis D in these cases occurred only when HBV infection took over, somehow giving HDV the support necessary to express its own pathogenicity [21]. In a study of cases in which HDV infection recurred in the graft, the time from chronic hepatitis to cirrhosis was found to be accelerated, as has been described for recurrence of HBV disease in the graft. This finding might be connected with the immunosuppression used in these patients, leading to an abortive immunological response like that seen in HIV positive patients. In patients affected by AIDS and chronic hepatitis D, B, or C, several studies have reported high levels of viremia [6, 25].
HCV and liver transplantation Following the discovery of hepatitis C virus (HCV) it was possible to analyze retrospectively patients who underwent OLT for cryptogenic cirrhosis and chronic non-A, non-B (NANB) hepatitis. The diagnosis of HCV infection was based on the detection of the anti-HCV antibody using an ELISA assay (II generation). Serum and liver HCV R N A was measured using an assay combining reverse transcription and polymerase chain reaction (RTPCR). In our series more than 80% of recipients with cryptogenic cirrhosis and chronic NANB hepatitis were positive for anti-HCV antibody after liver transplant. The analysis of 14 patients who had HCV R N A before transplant allowed the identification of a high rate (I0 of 14, 84%) of patients reinfected in the post-transplant period. In this type of viral infection there is a significant correlation between HCV replication before surgery and the post-transplant reinfection rate. By contrast, the acquisition of new HCV infection transmitted by transfusion was uncommon in our series. HCV infection in the graft reproduces the broad spectrum of liver disease seen in patients with chronic type C or NANB hepatitis; the histological forms described ranged from chronic hepatitis and cirrhosis to minimal hepatic lesions. An aspect that was observed in those cases reinfected with HCV R N A in serum and liver was the good correlation with elevated transaminase. This parameter in transplanted patients is very deceptive because there are many factors implicated in the specific rise of transaminases. However, the concomitant alteration of alanine transaminase associated with HCV replication in serum and liver supports the hypothesis that liver damage is related to HCV recurrence. Unfortunately we cannot rely on other markers of liver damage for this type of hepatitis as specific assays of virus related disease are not available. The in situ hy-
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bridization for H C V R N A staining in the hepatocytes was successful in liver sections from experimentally infected chimpanzees [18]. We hope that this procedure can soon be applied to h u m a n infection.
Conclusion A review of the literature of the past decade on liver transplantation for chronic viral hepatitis allows us to draw various conclusions. The first is that, o n long-term follow-up, the category of patients t r a n s p l a n t e d for end-stage chronic HBsAg positive hepatitis fare badly c o m p a r e d to those who where HBsAg negative before transplant. Patients infected with HCV before t r a n s p l a n t do better; although the reinfection rate of the grafts is c o m p a r a b l e to the other hepatitis viruses, the recurrence of liver disease seems to develop at a slower pace. Patients affected by HDV disease have a 50% chance of not developing recurrent disease in the graft, even after more t h a n 3 years of clinical follow-up. Finally, Iiver t r a n s p l a n t a t i o n is the best treatment available for f u l m i n a n t hepatitis; virus clearance is frequent. Since the i n t r o d u c t i o n of passive i m m u n o p r o p h y l a x i s in patients transplanted for cirrhosis type B and D the rate of allograft reinfection has been lower or reinfection has been delayed. At the same time, however, the cost of liver t r a n s p l a n t a t i o n in these patients has increased. This is because the i m m u n o p r o p h y l a x i s involved is a longterm or even p e r m a n e n t measure. It is therefore necessary to find cheaper alternatives to the products currently available. The hepatologist is at present faced with a controversial choice. Should patients suffering from chronic viral liver disease receive transplants when the majority of them will become reinfected? This is a particularly dramatic dilemma in Italy where liver disease is mostly viral in origin. Nevertheless, t r a n s p l a n t a t i o n prolongs survival and affords a much better quality of life, and we feel that patients with terminal viral hepatitis should continue to receive transplants. In the meanwhile every effort must be made to develop new methods of preventing recurrence.
References 1. Belli L, Dusheiko G, Rolles K, Burroughs AK, Liver transplantation for chronic viral hepatitis. Ital J Gastroenterol 23:36, 1991 2. Bismuth H, Samuel D, Gugenheim J, Castaing D, Bernuals J, Rueff B, Benhatnou JP, Emergency liver transplantation for fulminant hepatitis. Ann Intern Med 107:337, 1987 3. Bonino, F, IIoyer B, Nelson J, Engle R, Verrne G, Gerin JL, Hepatitis B virus DNA in the sera of HBsAg antigen carriers: a marker of active hepatitis B virus replication in the liver. Hepatology 1:386, 1981 4. Brunetto MR, Stemler M. Bonino F, A new hepatitis B virus strain in patients with severe anti-HBe positive chronic hepatitis B. J Hepatol 10: 258, 1990 5. Brunetto MR, Stemler M, Shodel F, Bonino F, Identification of an HBV variant which cannot produce precore derived HBeAg
and may be responsible for severe hepatitis. Ital J Gastroenterol 21: 151, 1989 6. Caredda F, Antinori S, Coppin P, Parravicini C, Vago L, Moroni M, The influence of human immunodeficiency virus infection on acute and chronic HBsAg-positive hepatitis, In: Gerin JL, Purcell RH, Rizzetto M (eds) The hepatitis delta virus. Wiley-Liss, New York, p 365, 1991 7. Carey WD, Tuthill R, Winkelman E, Clinical and pathological sequelae of orthotopic liver transplantation in chronic B hepatitis. In: Zuckerman AJ (ed) Viral hepatitis and liver disease. Liss, New York, p 801, 1988 8. Carman WF, Jacyna MR, Hadziyannis S, McGorvey M, Karayiannis P, Thomas HC, Mutation preventing formation of hepatitis B e antigen in patients with chronic hepatitis B infection. Lancet 2: 588, 1989 9. Chisari FV, Pinkert CA, Milich DR, Filippi P, McLachlan A. Palmiter RD, Brinster RL, A transgenic mouse model of the chronic hepatitis B surface antigen carrier state. Science 230:1157, 1985 10. Davies SE, Portmann BC, O'Grady JG, Aldis PM, Chaggor K. Alexander GJM, Williams R, Hepatic histological findings after transplantation, including a unique pattern of fibrosing cholestatic hepatitis. Hepatology 1: 150, 1991 11. Hoofnagie JH, Hanson RG, Minuk GY, Pappas SC, Schafer DE Dusheiko GM, Strauss SE, Randomized controlled trial of adenine arabinoside monophosphate for chronic type B hepatitis. Gastroenterology 86: 150, 1984 12. Kaneko S, Miller RH, Feinstone SM, Unoura M, Kobayashi K, Hattori N, Purcell RH, Detection of serum hepatitis B virus DNA in patients with chronic hepatitis using the polymerase chain reaction assay. Proc Natl Acad Sci USA 86: 312, 1989 13, Liang TJ, Hasegawa K, Riman N, Wands JR, Ben-Porath E, A hepatitis B mutant associated with an epidemic of fulminant hepatitis. N Engl J Med 324: 1705, 1991 14. Mason AL, Wick M, White HM, Benner KH, Lee RG, Riely CA, Bains VG, Kelley A, Campbell C, Parrillo RP, Increased hepatocyte expression of hepatitis B virus (HBV) RNA in fibrosing cholestatic hepatitis (FCH). Hepatology 4:58 A, Abstract 42, 1991 15. Mora N, Klintmalm GB, Poplawski SS, Cafer JB, Husberg JB. Gonwe TA, Goldstein RM, Recurrence of hepatitis B after liver transplantation: does hepatitis B immunoglobulin modify recurrent disease? Transplant Proc 22:1549, 1990 16. Muller R, Lauchart W, Farle M, Klein H, Niehoff G, Pichlmayer R, Simultaneous passive active immunization for preventing hepatitis B virus reinfection in hepatitis B surface antigen positive liver transplant recipients. J Med Virol 21: 115, 1987 17. Muller R, Gubernatis G, Farle MA, Liver transplantation in HBsAg positive graft recipients. Prevention of recurrence by passive immunization. J Hepatol 11 [Suppl 2]: $46A, 1990 18. Negro F, Pacchioni D, Shimizu Y, Miller RH, Bussolati G, Purcell RH, Bonino F, Detection of intrahepatic replication of hepatitis C virus RNA by in situ hybridization and comparison with histopathology. Proc Natl Acad Sci USA 89:2247, 1992 19. O'Grady L Williams R, Liver transplantation for viral hepatitis. Br Med Bull 46:481, 1990 20. Omata M, Ehata T, Yokosuka O, Hosoda K, Ohto M, Mutations in the precore region of hepatitis B virus DNA in patients with fulminant and severe hepatitis. N Engl J Med 324: 1699, 1991 21. Onobrelli A, Marzano A, Smedile A, Recchia S, Salizzoni M, Cornu C, Lamy ME, Otte JB, De Hemptinne B, Geubel A, Grendele M, Colledan M, Galmarini D, Marinucci G. Di Giacomo C, Agnes S, Bonino F, Rizzetto M, Patterns of hepatitis delta virus reinfection and disease in liver transplantation. Gastroenterology 101: 1649, 1992 22. Ponzetto A, Fiume L, Forzani B, Song SY, Busi C, Mattioli A, Spinetli C, Marinelli M, Smedile A, Chiaberge E, Bonino F, Gervasi GB, Rapicetta M, Verme G, Adenine arabinoside monophosphate and acyclovir monophosphate coupled to lac-
A. Smedile and M. Rizzetto: Liver transplantation for chronic viral hepatitis
23. 24. 25.
26.
tosaminated albumin reduce woodchuck hepatitis virus viremia at doses lower than do the unconjugated drugs. Hepatotogy 1:16, 1991 Rakela J, Woofen RS, Batts KP, Perkins JD, Taswell HF, Krom RA, Failure of interferon to prevent recurrent hepatitis B infection in hepatic allografts. Mayo Clin Proc 64:429-432, 1989 Rakela J, Recurrent hepatitis B infection in hepatic allograft. Mayo Clin Proc 64: 597, 1989 Rosina F, Smedile A. Caredda F, Fabiano A, Coppin P, Garripoli A, Gaiera G, Chiaberge E, Vago L, Bonino F, Rizzetto M, Verme G Unexpected serological patterns of HDV infection in anti-HIV positive patients. In: Proceedings of the 1990 International Symposium on Viral Hepatitis and Liver Disease, Houston, April 4-8, p 194, 1990 Samuel D, Bismuth A, Methieu D, Arulnaden JL, Reynes M, Benhamou JP, Brechot C, Bismuth H, Passive immunoprophy-
27. 28. 29. 30.
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laxis after liver transplantation in HBsAg positive patients. Lancet 37:813, 1991 Starzl TE, Demetris A J, Van Thiel D, Liver transplantation. N Engt J Med 15: t0t4. 1989 Starzl TE, Iwatsuki S, Van Thiel DH, Evolution of liver transplantation. Hepatology 2:614, 1982 Todo S, Demetris A J, Van Thiel D, Teperman L, Fung J J, Starzl TE, Orthotopic liver transplantation for patients with hepatitis B virus (HBV) related liver disease. Hepatology 13:619, 1991 Yoffe B, Burns DK, Bhah HS, Donegan E, Ferrell L, Asher WL, Roberts JP, Extrahepatic hepatitis B virus DNA sequences in patients with acute hepatitis B infection. Hepatology 12:187. 1990
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Orthotopic liver transplantation for chronic viral hepatitis: an overview A. Smedile and M. Rizzetto* Division of Gastroenterology, Molinette Hospital and * Institute of Internal Medicine, University of Turin, Corso Bramante 88, 1-10126 Turin, Italy
Summary. The aim of this review is to discuss the problem of orthotopic liver transplantation in patients suffering from chronic viral liver disease due to hepatitis B, C and D viruses. The decision to operate these patients is often controversial, as the risk of a recurrence of viral infection is very high and reinfection may be severe enough to require a second or even multiple grafts. However, the quality of life and the survival rate improve after transplantation in chronic viral hepatitis patients.
for patients with end-stage organ failure. It is only in the 1990s, therefore, that surgeons and hepatologists have begun to reanalyze their cumulative data on the basis of the original liver infection of the patient, in order to identify factors that influence the outcome of the graft in the long term.
Chronic hepatitis B and liver transplantation Key words: Orthotopic liver transplantation - Reinfection - Chronic hepatitis
Brief history of orthotopic liver transplantation A brief outline of the short history of orthotopic liver transplantation (OLT) will help to understand why the original liver infection of the patient has only become such an important issue in the last few years. Each new step in the history of OLT has been characterized by a major obstacle which has had to be overcome, using the best means available, before the next step can be taken. In the late 1960s and the 1970s the greatest problem for surgeons and hepatologists was the limitations imposed by the surgical techniques of the day. Few patients survived surgergy and the few that did were not enough to counterbalance the high mortality rate. In the late 1970s the survival rate ( 6 0 - 7 0 % at 5 years) at last outweighed the mortality rate. At this point attention focused on the question of immunosuppression and its optimal management in cases of acute and chronic rejection. The introduction of cyclosporin A in 1980 was the real breakthrough, not only for liver transplantation but also for all organ transplants. Cyclosporin A may indeed be considered the true promoter of OLT as a therapeutic procedure Correspondence to: M. Rizzetto
In the initial years of liver transplantation it was difficult to draw a clear picture of patients transplanted for viral cirrhosis type B because of the lack of serological data. Patients were generally classified as having hepatitis B virus (HBV)-related or post-necrotic cirrhosis [27]. Subgrouping into HBsAg positive and HBsAg negative, or as having, or not, markers of past HBV infection, showed clearly that the presence of HBV was a risk factor for reinfection of the graft and for the reappearance of liver disease with a worse long-term outcome. Today the risk of reinfection in candidates with active HBV infections is almost 9 0 - 1 0 0 % in nearly all series. and its appearance may be detected at various intervals after surgery [1]. Many problems still remain unresolved in the management of these patients. We will analyze the limitations that have become apparent from experience in this particular category of recipients and discuss the role of HBV replicative status before liver transplant, and its significance given the improvement in tests for HBV gehome detection. We will also examine the clinical course of HBV patients transplanted for fulminant hepatitis B (FH). Both patients with liver failure resulting from a long-lasting chronic liver disease and previously healthy individuals with an acute HBV infection with a potentially fatal course (FH) are candidates for OLT. The final point to be analyzed and discussed is what measures of prophylaxis and therapy should be recommended in order to prevent reinfection of the graft. Particular attention will be devoted to protocols being studied at the moment.
212
A. Smedile and M. Rizzeno: Liver transplantation for chronic viral hepatilis
Influence of H B V replication on the recurrence of infection in the graft The subtype of chronic hepatitis B in the recipient plays a major role in the recurrence of infection. An analysis of early studies on HBsAg positive disease showed that the replicative status of HBV with the expression of the hepatitis B e antigen (HBeAg) was associated with increased morbidity and mortality in many series [7, 19, 23]. Testing for the HBe/anti-HBe antibody system was used initially to separate carriers of HBsAg with high levels of viremia (HBeAg positive), from those with lower replication (anti-HBe positive). This division was thought to be relatively accurate until the HBV DNA assay was introduced for testing viral replication in serum and liver [3], By measuring levels of DNA at a concentration of a pg/ng per ml, it was possible to reveal HBV sequences even in anti-HBe positive carriers [4]. In a recent study performed at Villejuif, Paris, it was demonstrated that patients who were HBV DNA positive prior to liver transplant had a much greater risk of HBsAg recurrence than patients who where HBV DNA negative (96% vs 29%) at 2 years [26]. A similar experience has been reported by the Pittsburgh group, who have reexamined 51 HBsAg positive patients. Recurrence of HBV in the new liver was the leading cause of mortality occurring after 3 months and was also implicated in 11 (73%) of 15 deaths that occurred during or soon after the operation. Moreover, HBV reinfection was the sole reason for multiple retransplantation in this group [29]. In our series of seven patients transplanted for HBV cirrhosis, six were reinfected within 2 years; all six were anti-HBe positive and all were HBV DNA negative by dot-blot hybridization assay. Recurrence of liver disease in the graft was the rule with an episode of acute hepatitis leading to chronic hepatitis and cirrhosis. The course of recurrent hepatitis to cirrhosis was often more rapid than natural infection (6 months to 1 year). One patient received a second liver transplant for graft failure less than I year after the first graft. Such findings give new insights into the mechanisms used by HBV to cause cellular damage in the graft. For instance, the immunosuppression given to the patient seems to contradict the theory of immunological damage, while it appears that the virus in itself can be pathogenic [8]. A peculiar histological pattern of disease in some patients with recurrent HBV infection was identified in the Cambridge King's College Hospital series. This form, termed fibrosing cholestatic hepatitis (FCH), was associated with rapidly progressive graft dysfunction. The pattern of cell damage described as FCH was characterized by signs of cholestasis and periportal fibrosis; more discriminatory was the presence of abundant tissue HBsAg staining in the allografts [10]. An explanation for these findings was an overexpression of HBsAg proteins with accumulation of the product in the hepatocytes. These pathological features were supported by another transplantation group [14]. By using the in situ hybridization technique with single-stranded probes, this group was able to discriminate between HBV DNA and HBV RNA strands. They found increased staining for HBV RNA
only in livers from recipients with FCH [14]. The only experimental model in which there was overexpression of HBsAg with damage to the hepatocytes was the transgenic mouse model developed by Chisari and coworkers [9]. In this model the overproduction of surface antigen caused an overload of surface proteins with a direct cytotoxic effect. This mimicked the damage caused by metabolic liver disorders. Results in fulminant hepatitis B Viral hepatitis is the most common cause of acute liver failure worldwide. Liver transplants have changed the poor prognosis of FH dramatically. Before the use of liver transplantation, the mortality rate of patients suffering from FH was almost 90%, although those few who survived the virus attack did well, showing serological markers of HBV clearance [2]. Using OLT as the primary therapeutic option for FH has resulted in 1-year survival rates of 5 0 - 7 0 % in many series published in Europe and North America [27]. More important, recurrence o f HBV infection at medium- and long-term follow-up has been negligible (0/17 at 2 years, Villejuif; 1/8 at 4 years, Pittsburgh). In this context, it appears that the prior HBV replicative status does not influence the rate of recurrence in the graft, even though the majority of the recipients were positive for HBV DNA in pretransplant sera. An explanation for this finding might lie in the massive necrosis of infected hepatocytes and the early elimination of viremia which is characteristic of FH. During the fulminant course, serological markers of HBV infection are usually not found, with the exception of early indicators such as high titers of IgM anti-HBc or HBV DNA, using the PCR assay [12]. By contrast, patients with chronic HBV infection and stable viremia have a higher risk of reinfection. A recently recognized virologic aspect concerns mutations appearing in the precore region. The emergence of these mutants may explain severe outbreaks of acute hepatitis in Israel and Japan [13, 20]. Transplantation, however, may have a more favorable outcome when mutant strains of HBV are involved, presumably due to a selection of mutated virions that are less infectious than the wild-type virus. Patients affected by anti-HBe positive/HBV DNA positive chronic hepatitis often show a point mutation at nucleotide 1896 which makes the core genome unable to synthesize the e protein by producing a stop codon [5]. The appearance of specific mutations in nucleotide sequences belonging to regulatory genes may interfere with the production of viral antigens that are expressed in the hepatocyte membranes as targets for the immune system. Measures to prevent H B V recurrence Two different approaches were adopted to prevent HBV recurrence in the graft. The first measure was based on the use of hyperimmunoglobulin anti-HBs (HBIg), given at liver transplantation and maintained for days or weeks, according to the different protocols. The purpose was the neutralization of any HBV particles that had
A. Smedile and M. Rizzetto: Liver transplantation for chronic viral hepatitis been passively transferred during surgery. At the beginning it was thought that this strategy might be effective in the short term. However, when the administration of HBIg was stopped, reinfection took place at a rate similar to that in the unprotected patients [15]. The combination of HBIg with active immunization using recommended doses of HBV vaccine did not afford better results [16]. A successful strategy has been reported by the Hanover transplantation group, using prolonged passive immunoprophylaxis [17]. The protocol was applied to a group of 23 HBsAg positive recipients. Policlonal HBIg was given at a dose of 10000 IU during the anhepatic phase and for the first 8 days following transplantation. The antibody titer was kept at a level of 100 UI for 6 months in I1 patients and for t2 monts in 12 patients. The outcome in treated patients was compared with the outcome in an original group of 11 patients who received HBIg in the anhepatic phase only or not at all. Recurrence of HBV invariably affected the control group, while reinfection did not occur in over 80% of the recipients under HBIg prophylaxis. The outcome was even better for those candidates who were negative for HBV DNA in pretransplant serum samples. Unfortunately, this promising solution can be very expensive if the patients have to be maintained under immunoprophylaxis indefinitely. There are commercially available preparations of monoclonal immunoglobulins which are 5000 times more concentrated; however, they also represent no more than a temporary solution. The real problem lies in the systemic spread of viral particles. HBV D N A replicative species can be detected in extrahepatic tissues such as spleen, pancreas, kidneys and mononuctear cells [30]. These organs act as a reservoir; HBV particles can be harbored in them for a long time and then be reactivated under favorable conditions. The second approach to the prevention of HBV recurrence in the allograft was based on attempts to treat patients with chronic hepatitis B. One of the first studies used preoperative interferon therapy [23]. This study administered an 8-day course of interferon before transplantation and 3 months of interferon therapy after transplantation. However, viremia and liver disease appeared postoperatively. Other trials of combined antiviral therapy (ARA-AMP) and OLT have all resulted in allograft reinfection [11]. These discouraging results have stimulated new measures. One proposal is the administration of the antiviral agent A R A - A M P labeled with albumin before OLT, to abate levels of HBV viremia. Direct delivery of this targeted compound to the hepatocytes has successfully reduced viral replication in the woodchuk model [22]. However, courses of low-dosage interferon before surgery in severely ill patients have sometimes acutely decompensated the patients, necessitating OLT as an emergency procedure.
HDV and liver transplantation The experience with cirrhosis due to hepatitis D virus (HDV) requiring liver transplantation has been generally
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favorable. The reinfection rate after transplantation ranges from 57 to 77%, with good clinical outcome in 50% of cases. The pretransplant HDV replication status appears not to affect the rate of reinfection. In recipients who were reinfected 3 - 6 months after OLT, the infection ran a course similar to that of natural infection, reproducing a typical pattern of coinfection. Some patients were infected very early in the absence of demonstrable HBV infection, as shown by the presence of delta antigen in the hepatocytes and sporadic positivity to HDV RNA in serum and by the absence of HBV markers. The recrudescence of hepatitis D in these cases occurred only when HBV infection took over, somehow giving HDV the support necessary to express its own pathogenicity [21]. In a study of cases in which HDV infection recurred in the graft, the time from chronic hepatitis to cirrhosis was found to be accelerated, as has been described for recurrence of HBV disease in the graft. This finding might be connected with the immunosuppression used in these patients, leading to an abortive immunological response like that seen in HIV positive patients. In patients affected by AIDS and chronic hepatitis D, B, or C, several studies have reported high levels of viremia [6, 25].
HCV and liver transplantation Following the discovery of hepatitis C virus (HCV) it was possible to analyze retrospectively patients who underwent OLT for cryptogenic cirrhosis and chronic non-A, non-B (NANB) hepatitis. The diagnosis of HCV infection was based on the detection of the anti-HCV antibody using an ELISA assay (II generation). Serum and liver HCV R N A was measured using an assay combining reverse transcription and polymerase chain reaction (RTPCR). In our series more than 80% of recipients with cryptogenic cirrhosis and chronic NANB hepatitis were positive for anti-HCV antibody after liver transplant. The analysis of 14 patients who had HCV R N A before transplant allowed the identification of a high rate (I0 of 14, 84%) of patients reinfected in the post-transplant period. In this type of viral infection there is a significant correlation between HCV replication before surgery and the post-transplant reinfection rate. By contrast, the acquisition of new HCV infection transmitted by transfusion was uncommon in our series. HCV infection in the graft reproduces the broad spectrum of liver disease seen in patients with chronic type C or NANB hepatitis; the histological forms described ranged from chronic hepatitis and cirrhosis to minimal hepatic lesions. An aspect that was observed in those cases reinfected with HCV R N A in serum and liver was the good correlation with elevated transaminase. This parameter in transplanted patients is very deceptive because there are many factors implicated in the specific rise of transaminases. However, the concomitant alteration of alanine transaminase associated with HCV replication in serum and liver supports the hypothesis that liver damage is related to HCV recurrence. Unfortunately we cannot rely on other markers of liver damage for this type of hepatitis as specific assays of virus related disease are not available. The in situ hy-
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bridization for H C V R N A staining in the hepatocytes was successful in liver sections from experimentally infected chimpanzees [18]. We hope that this procedure can soon be applied to h u m a n infection.
Conclusion A review of the literature of the past decade on liver transplantation for chronic viral hepatitis allows us to draw various conclusions. The first is that, o n long-term follow-up, the category of patients t r a n s p l a n t e d for end-stage chronic HBsAg positive hepatitis fare badly c o m p a r e d to those who where HBsAg negative before transplant. Patients infected with HCV before t r a n s p l a n t do better; although the reinfection rate of the grafts is c o m p a r a b l e to the other hepatitis viruses, the recurrence of liver disease seems to develop at a slower pace. Patients affected by HDV disease have a 50% chance of not developing recurrent disease in the graft, even after more t h a n 3 years of clinical follow-up. Finally, Iiver t r a n s p l a n t a t i o n is the best treatment available for f u l m i n a n t hepatitis; virus clearance is frequent. Since the i n t r o d u c t i o n of passive i m m u n o p r o p h y l a x i s in patients transplanted for cirrhosis type B and D the rate of allograft reinfection has been lower or reinfection has been delayed. At the same time, however, the cost of liver t r a n s p l a n t a t i o n in these patients has increased. This is because the i m m u n o p r o p h y l a x i s involved is a longterm or even p e r m a n e n t measure. It is therefore necessary to find cheaper alternatives to the products currently available. The hepatologist is at present faced with a controversial choice. Should patients suffering from chronic viral liver disease receive transplants when the majority of them will become reinfected? This is a particularly dramatic dilemma in Italy where liver disease is mostly viral in origin. Nevertheless, t r a n s p l a n t a t i o n prolongs survival and affords a much better quality of life, and we feel that patients with terminal viral hepatitis should continue to receive transplants. In the meanwhile every effort must be made to develop new methods of preventing recurrence.
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