Long-term outcomes of liver transplantation using grafts from donors with active hepatitis B virus replication: a multicenter cohort study

Abstract

Purpose: Liver grafts from donors with HBV infection contributed to expanding the donor pool under the hepatitis B immunoglobulin and antiviral agents (nucleos(t)ide analogues) in the HBV-endemic area. We report long-term outcomes of liver transplantations (LTs) using grafts from donors with active or chronic HBV infection.

Methods: Overall, 2,260 LTs performed in 3 major hospitals in Seoul from January 2000 to April 2019 were assessed for inclusion. Twenty-six grafts (1.2%) were obtained from HBsAg (+), HBeAb (+), or HBcAb (+) donors, and recipient outcomes were retrospectively reviewed. Donor and recipient demographics and transplantation outcomes were analyzed.

Results: Sixteen deceased donor LTs were performed using active HBsAg (+) grafts. Ten other LTs were sourced from 10 living donors. There was no significant difference in survival in patients who received deceased donor LTs compared with that in those who underwent LT with non-hepatitis virus-infected grafts. Fourteen patients who were followed up for >5 years were stable, and no difference in hepatocellular carcinoma recurrence rate was observed 5 years after transplantation between transplants from donors with and those without HBV.

Conclusion: Considering long-term outcomes, liver grafts from donors with active HBV replication can be safely used for LT.

Keywords: Hepatitis B virus; Hepatocellular carcinoma; Liver transplantation; Marginal graft; Outcome.

Fig. 1. Flow chart of the study population. Three patients were excluded as their serology results were considered to be false positives following consultation with a hepatologist. Twenty-six donors were regarded as having active (deceased donor liver transplantation, DDLT) or chronic (living donor liver transplantation, LDLT) HBV infection. All deceased donor liver transplantations used HBsAg (+) grafts. All living donors had chronic hepatitis with HBsAg (–) seroconversion. Serum liver enzyme levels were within the normal ranges in all donors.

Fig. 2. HBV infection stage of donors and recipients, as well as transplantation outcomes and perioperative management of each patient. Eight donors with HBcAb (+) HBV DNA (+) were regarded as cases of resolving HBV, an immune-inactive stage with low viral replication. The other 2 donors had HBeAg (+) chronic HBV infection with HBsAg seroconversion. D is marked at the end of the arrow of deceased recipients. Hepatitis B immunoglobulin (HBIG) was administered as a maintenance dose after induction. The operator decided the dose based on the HBV infection statuses of the donor and recipient. The same principle was applied to dosages of antiviral agents. Pre (D) indicates the HBV infection stage of donors, pre (R) indicates that of recipients before transplantation, and post (R) indicates that of recipients after transplantation. R, resolution; I, inactive; CH, HBeAg (–) chronic hepatitis; V, vaccinated; CHP, HBeAg (+) chronic hepatitis; CPH, HBe-positive chronic hepatitis with HBV seroconversion; HCV+, HCV DNA positive; L, lamivudine; A, adefovir; E, entecavir; T, tenofovir; PegIFN, pegylated interferon a2a; POD, postoperative day.

Fig. 3. Kaplan-Meier curve for recipient survival. (A) HBV infection status of the donor did not affect recipient survival (P = 0.247, log-rank test). (B) All reported deaths occurred in patients who received HbsAg (+) grafts.