Objectives: Hepatitis B and D virus coinfection or superinfection lead to chronic liver disease and have poor treatment results and poor prognosis. After transplant, these patients have difficult problems. We aimed to report long-term data of liver transplant recipients who had hepatitis B and D virus-related chronic liver disease.

Materials and Methods: This retrospective, longitudinal study included 25 consecutive hepatitis B surface antigen-positive patients with anti­hepatitis D virus antibodies. Patient data (age, sex, antiviral treatment, posttransplant use of hepatitis B hyperimmunoglobulin and/or nucleoside/nucleotide analogues, the presence of hepatocellular carcinoma, age at transplant, follow-up) were extracted from patient records.

Results: Females comprised 32% patients. The median age was 44 years (range, 23-63 y). The serum Hepatitis B envelope antigen level was negative in all patients. At the time of transplant, 4 patients were positive for hepatitis B virus DNA and 11 patients also had hepatocellular carcinoma. Posttransplant follow-up was 59 months (range, 3-120 mo). During follow-up, 4 patients died, 4 patients were lost to follow-up, and 17 patients were alive. Posttransplant survival of patients with hepatocellular carcinoma was 50.45 months (range, 3-84 mo) and without hepatocellular carcinoma was 65.8 months (range, 4-120 mo). There were 3 patients who had acute rejection and were treated successfully with pulse doses of prednisolone. Hyperimmunoglobulin therapy was used in conjunction with oral nucleotide/nucleoside analogues for 12 months (range, 3-24 mo) and then stopped. After transplant, 4 patients had antiviral medicine changed to adefovir or entecavir because of drug resistance, and otherwise all patients remained negative for hepatitis B virus DNA during follow-up.

Conclusions: Patients transplanted for hepatitis B and D virus cirrhosis, even with hepatocellular carcinoma, had favorable prognosis and good long-term results. Close follow-up of patients and effective viral suppression with suitable drugs were key factors for efficient patient care.

Key words : Antiviral, Cirrhosis, Coinfection, Hepatocellular carcinoma, Therapy

Introduction

Rizzetto and colleagues discovered hepatitis delta virus (HDV) in the mid-1970s while investigating a group of patients with hepatitis B virus (HBV) who had severe hepatitis.¹ The HDV is a single-stranded RNA virus similar to viroids of plants that is coated in hepatitis B surface antigen (HBsAg), and presence of HBV is crucial for the completion of its life cycle. The HDV is thought to be entirely dependent on HBV for its replication and expression.² Infection by HDV can be either a coinfection (simultaneous transmission with HBV) or superinfection (new infection in people who already are chronic HBV carriers).³ It has been estimated that 15 to 20 million people worldwide have chronic HDV infection, and there are substantial geographic differences.^3-5 Approximately 5% HBsAg-positive patients also are infected with HDV.⁶ The HDV infection has a worldwide distribution and is endemic in the Middle East, Mediterranean area, Amazon region, and many African countries.7

Chronic HDV occurs as superinfection in 90% and coinfection in 10% patients. Chronic HDV infection frequently is associated with active chronic hepatitis that leads to cirrhosis in 70% patients in 5 to 10 years.^8,9 Patients with chronic HDV infections have more rapidly progressive liver damage than patients infected with HBV alone.¹⁰ The incidence of cirrhosis is 3-fold higher in patients with HBV/HDV chronic coinfection than chronic HBV monoinfection, with a higher risk of early decompensation and development of hepatocellular carcinoma (HCC).^9,11 Therefore, HDV infection in the world is an important health burden. The only established treatment for chronic HDV is interferon at high doses, but interferon therapy is associated with therapeutic success in only 25% to 30% treatments.^12,13

Chronic infection with HDV is a risk factor for cirrhosis and HCC.14 However, a high proportion of patients are lost due to cirrhosis and its complications or HCC unless they receive orthotopic liver transplant.¹⁵ The HBV DNA integrates into the host DNA and shows a series of potentially oncogenic properties, but HBV is not an acutely transforming virus because HCC develops decades after infection. Other factors such as cirrhosis, inflammation, alcohol intake, and viral superinfection could promote the oncogenic process induced by HBV DNA integration.¹⁶

After transplant, these patients have different and difficult problems. The aim of our study was to report the long-term data of our liver transplant recipients who had HBV/HDV-related chronic liver disease. In this retrospective cohort, we examined posttransplant follow-up data that extended up to 10 years.

Materials and Methods

Patients and hepatitis assays
This study was a retrospective, longitudinal study that included 25 consecutive HBsAg-positive patients with anti-HDV antibodies who were referred to the Department of Gastroenterology and Hepatology, Baskent University Medical Faculty between 2003 and 2014. The HBV and HDV infections were diagnosed by commercially available enzyme-linked immunosorbent assays for HBsAg and anti-HDV antibody. The data about patients were extracted from patient records including age, sex, pretransplant treatment, pretransplant liver imaging, explant liver pathology, antiviral treatment, posttransplant use of hepatitis B hyperimmuno­globulin (HBIg) and/or nucleoside/nucleotide analogues, presence of HCC, follow-up, and tumor recurrence.

Other serum assays
Pretransplant serologic profiles were analyzed thoroughly including HBsAg, AntiHBs, hepatitis B e antigen (HBeAg), hepatitis B core immunoglobulin G (HBc-IgG), antihepatitis C virus (anti-HCV), anti-HDV, HBV DNA, and HDV RNA. Lamivudine-resistant mutations were evaluated in patients who had virologic (HBV DNA) or biochemical (liver enzyme) nonresponse or HBV reactivation, which was defined by reappearance or elevation of HBV DNA in patients who were inactive previously.

Liver imaging
The imaging of the liver was performed by both ultrasonography and dynamic liver computerized tomography before and after transplant when needed.

Liver biopsy
The histopathologic examination of liver tissue samples was performed before and after liver transplant. The pathologic examination focused mainly on general evaluation before transplant, presence of posttransplant rejection, and evaluation of possible recurrence of HBV or HDV hepatitis. Explanted livers of all patients were examined.

Statistical analyses
Statistical analyses were performed with software (IBM SPSS Statistics for Windows, Version 21.0, IBM Corp., Armonk, NY, USA). The chi-square test and Fisher exact test were used to compare nominal data between groups. Comparison of numeric variables was performed with Mann-Whitney U test. The level of significance was considered to be P ≤ .05.

Results

The data of 25 patients with chronic HBV/HDV and HBeAg negative who underwent liver transplant were evaluated. Females comprised 32% patients (17 male and 8 female patients). The median age was 44 years (range, 23-63 y) at transplant. The mean pretransplant waiting period after listing was 19 months (range, 1-54 mo) (Table 1). After liver transplant, the patients were treated with one or with multiple immunosuppressive therapy such as mycophenolate mofetil, tacrolimus, sirolimus, and everolimus.

At transplant in all patients, serum HBsAg levels were positive but AntiHBs and HBeAg levels were negative. Interferon treatment was used prior to transplant in 6 patients; 2 of these patients received interferon for 2 months and 7 months, and 4 patients completed 12 months interferon treatment. At transplant, 4 patients tested positive for HBV-DNA and these patients were started on entecavir or lamivudine therapy. The other 2 patients tested positive under lamivudine treatment; 1 of these patients was changed to adefovir and the other patient had adefovir add-on treatment. There were 20 patients who used lamivudine treatment and 1 patient received adefovir treatment.

All patients had liver cirrhosis before transplant according to imaging techniques, liver biopsies, and examination of explanted livers. The examination of explanted livers showed HCC in 11 patients, including 2 patients in whom the tumors were not detected by imaging techniques. The application of Milan criteria revealed that only 7 of 11 tumors matched Milan criteria and 4 patients did not match Milan criteria. There were 24 patients who had living-donor transplant and 1 patient who had deceased-donor transplant.

Hyperimmunoglobulin therapy was used in conjunction with oral nucleotide/nucleoside analogues for 12 months (range, 3-24 mo) and then stopped. After transplant, 4 patients had antiviral medicine changed to either entecavir or adefovir because of drug resistance, and otherwise all patients remained HBV-DNA-negative during follow-up. After stopping hyperimmunoglobulin therapy, 6 patients were HBsAg-positive and 8 patients remained anti-HBs-positive.

Recurrence of HCC was observed in 2 patients (not matching Milan criteria) at 2 years after transplant. There was 1 patient who was lost to follow-up, and the other patient was successfully treated with radiofrequency ablation, transarterial chemoembolization, and sorafenib treatment.

Posttransplant survival of patients with HCC was 50.45 months (range, 3-84 mo) and without HCC was 65.8 months (range, 4-120 mo). Survival plots in patients with or without hepatocellular carcinoma were shown (Figure 1). The 1-, 3-, and 5-year survival after liver transplant in our patients with or without hepatocellular carcinoma was shown (Figure 2). Posttransplant follow-up was 59 months (range, 3-120 mo). During follow-up, 4 patients died, 4 patients were lost to follow-up, and 17 patients were alive. The timing of death was within 5 months after transplant in 3 patients, and the fourth patient died at 72 months posttransplant. Cause of death was pulmonary aspergillosis in 1 patient and sepsis in 3 patients. In 4 patients lost to follow-up, mean follow-up was 48.5 months (range, 24-84 mo). There were 3 patients who experienced acute rejection and were treated successfully with pulse doses of predni­solone.

Discussion

Persistent HBV/HDV coinfection results in end-stage liver disease and 15% mortality.¹⁷ The range of clinical presentation is wide, varying from mild disease to fulminant liver failure, end-stage liver disease, and HCC. Although HDV infection is less commonly observed, chronic HDV infection leads to more severe liver disease than HBV monoinfection. This accelerated phase is characterized by accelerated fibrosis progression, earlier hepatic decompensation, and an increased risk for the development of HCC.^18,19 The incidence of HDV infection has decreased in endemic countries as a result of effective immunoprophylaxis against HBV and improvement in socioeconomic and hygienic conditions.^20-22 The only definitive therapy for patients with end-stage liver disease, HCC, or fulminant hepatitis due to HDV is liver transplant.²³ The HBV/HDV coinfection was noted in 2% patients who had liver transplant in 2009 across Europe.²⁴

Chronic liver disease related to HBV/HDV coinfection has 7% to 9% annual mortality rate. The 2- to 5-year follow-up of these patients in developing cirrhosis is 20% to 50%. In a study by Gheorghe and associates, HDV-related cirrhosis had a median time to decompensation < 2 years and median survival < 5 years, and almost all deaths were liver-related.²⁵ In another study, a total of 299 HBV/HDV patients had been followed for a mean 223 months. At the time of first evaluation, 113 patients had chronic hepatitis and 186 patients had cirrhosis. In the chronic hepatitis subgroup, 75 patients were alive, 9 patients were dead, and 29 patients were lost to follow-up with neither decompensation nor HCC. In the cirrhosis subgroup, 46 patients had developed HCC and 54 patients had progressed to decompensated cirrhosis.¹⁷ Romeo and associates reported that among the 105 patients with chronic hepatitis at baseline, ³¹ patients (29%) developed cirrhosis, 10 patients (9%) developed HCC, 7 patients (6%) developed liver decompensation, and 7 patients (6%) died of liver-related events.¹⁴

Chronic HDV has been considered primarily an HBeAg-negative disease. Biochemical activity of liver disease is more severe in patients who have HDV with HBeAg-positive than HBeAg-negative serology. The HBeAg-positive patients have significantly higher HBsAg levels than HBeAg-negative patients.²⁶ Although severe HDV occurs in patients who are HBeAg-positive,^27,28 the percentage of liver transplant recipients is higher in HBeAg-negative patients. In our patients, the anti-HBe antibody positive rate was 100%. This comparison is not available in our study because all patients were anti-HDV-positive/HBeAg-negative.

The survival of patients depends on the prevention of allograft reinfection, acute or chronic rejection, and progression in patients who have recurrent disease. Data from different centers reveal a range of 77% to 85% 5-year posttransplant survival in patients who have HDV-related chronic liver disease.^29-31 The cumulative 1-, 3- and 5-year surveillance in our patients was 88%, 79%, and 74%.

The overall outcomes following liver transplant are better in patients with HDV than patients transplanted for HBV alone.^29,31,32 The presence of HDV infection appears to provide a protective effect against HBV reinfection, possibly via suppression of HBV replication.³³ In contrary to the well-known belief that the presence of HDV suppressed HBV replication, a recent study showed a higher degree of replicative activity of either or both viruses.³⁴ In patients with HBV/HDV coinfection after transplant, recurrence of HBV or HDV can occur. In the 1990s, several studies on patients with liver transplant for HDV-related liver disease showed that patients who had no or short-term HBIg prophylaxis showed a high rate of HDV reinfection (70%-82%) with a lower rate of hepatitis recurrence (40%) in the graft recipients and a milder course of hepatitis than patients who had HBV.^29,35 The clinical course after transplant can be improved further by long-term administration of HBIg with recurrence of HBsAg in only 9% patients.³¹ The use of low-dose intra­muscular HBIg and antiviral prophylaxis in combination results in < 5% rate of recurrent HBV-HDV infection.

There are various strategies for using HBIg in the posttransplant setting, and in our institution we have a definite period of HBIg use which is limited to a maximum 24 months posttransplant. Before routine prophylaxis against HBV, recurrence was almost universal in the 1990s.²⁹ Although there are several regimens available against viral recurrence after liver transplant, HBIg is given in our patients. In our center, the dosing of HBIg is 10 000 IU in the anhepatic phase, 2000 IU daily during the first week, and subsequent doses to maintain anti-HBs levels > 100 IU/L for mean 12 months (3-24 mo). The oral nucleoside/nucleotide analogues started before liver transplant were continued after liver transplant. Only 4 patients required modification because the viral breakthrough on lamivudine (3 patients) or deterioration of renal function on adefovir (1 patient). At last follow-up, HBsAg was positive in only 3 of 17 patients, with 2 patients at 6 months after transplant, but we do not know the long-term results. In all other 14 patients that were negative for HBs Ag and HBV DNA are provided. In all patients, HBV suppression (defined by HBV DNA negativity) was achieved by oral antiviral prophylaxis by lamivudine (12 patients), entecavir (3 patients), and adefovir (2 patients).

In recent years, much published evidence suggests that there is an increased risk of malignant transformation in the presence of HDV/HBV coinfection than HBV infection alone.^16,36 Cells infected with HDV have altered gene expression and cellular responses, which is also evident from augmented expression of proinflammatory, growth, and antiapoptotic factors.³⁷ In an Italian study, 9% patients were coinfected with HBV and HDV, and 13% of those patients that had cirrhosis developed HCC during a 10-year follow-up.¹³ Romeo and associates diagnosed HCC in 46 of 299 patients (15%) and reported that the risk of developing HCC was affected by previous treatment with interferon and persistent HBV replication.¹⁷ Fattovich and associates reported that HCC developed in 5 patients (13%) that were anti-HDV-positive/HBeAg-negative and 19 patients (16%) that were anti-HDV negative/HBeAg-negative with cirrhosis; concomitant HDV infection was associated with a 3-fold increased risk of HCC and 2-fold increased risk of mortality.19 In a retrospective study with HBV/HDV, 29 of 299 patients diagnosed with HBV/HDV had liver transplant; in these 29 patients, 10 patients (34%) with HCC were available. After transplant, 5 patients died (3 with primary graft failure, 1 with tumor recurrence, and 1 with nonliver–cancer-related reasons).¹⁷

Patients with HCC matching Milan criteria are most likely to benefit from liver transplant, with 5-year survival rates of 70% and a recurrence rate < 10%.38 The application of Milan criteria revealed that only 7 of 11 tumors were matching with Milan criteria and 4 patients were not matching Milan criteria (in whom 2 patients had HCC recurrence after 2 years). The recurrent tumors were treated by ablation techniques and this resulted in excellent 5-year survival.

In conclusion, we presented our liver transplant experience in patients with HBV/HDV. Our data suggest that in patients with liver transplant who have HBV/HDV-positive hepatitis, anti-HBs immunoglobulin, and antiviral drugs may be useful by reducing HBV and HDV reinfection. In our patient cohort, recurrent HCC was successfully treated by radiologic interventions such as transcatheter arterial chemoembolization, radiofrequency ablation, and sorafenib. Viral prophylaxis changes the natural history of liver disease after liver transplant. Definite use of HBIg is an original treatment strategy in these patients.

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