Prevention of lamivudine-resistant hepatitis B recurrence after liver transplantation with entecavir plus tenofovir combination therapy and perioperative hepatitis B immunoglobulin only

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http://onlinelibrary.wiley.com/doi/10.1111/j.1399-3062.2010.00591.x/abstract

Prevention of lamivudine-resistant hepatitis B recurrence after liver

transplantation with entecavir plus tenofovir combination therapy and

perioperative hepatitis B immunoglobulin only

T. Karlas1, J. Hartmann1, A. Weimann2, M. Maier 3, M. Bartels2, S. Jonas2, J.

Mössner1, T. Berg1, H.L. Tillmann1,4, J. Wiegand1

Article first published online: 16 DEC 2010

DOI: 10.1111/j.1399-3062.2010.00591.x

© 2010 Wiley & Sons A/S

Issue

Transplant Infectious Disease

Volume 13, Issue 3, pages 299–302, June 2011

Abstract: Combination therapy with antivirals plus hepatitis B immunoglobulin

(HBIg) has become the standard treatment for prevention of post-liver transplant

hepatitis B virus (HBV) recurrence. However, HBIg therapy is inconvenient and

expensive. Alternative therapeutic approaches with modern nucleos(t)ide

analogues are limited so far. The present case report describes prevention of

HBV recurrence with entecavir and tenofovir. A 48-year-old male patient with

hepatitis B-induced decompensated liver cirrhosis initially improved on

lamivudine (LAM) until LAM resistance (rtL180M and rtM204V) emerged followed by

renewed decompensation. Therefore, tenofovir was added to LAM leading to

undetectable HBV DNA (<200 copies/mL). Six months later, low-level viremia (479

copies/mL) was detected. Treatment was escalated to tenofovir plus entecavir.

HBV DNA became negative again, and the patient underwent orthotopic liver

transplantation. HBIg was administered during transplantation (10,000 IU) and on

the second and third postoperative days (total dose 26,000 IU). Subsequently,

the anti-hepatitis B surface (HBs) titer rose to 1477 IU/L at day 4 post

transplantation. Although HBIg should have been continued, the patient remained

on combination therapy with tenofovir plus entecavir only. The anti-HBs titer

decreased and became negative 4 months later. However, under continued

combination therapy with oral antivirals, HBV DNA and hepatitis B surface

antigen remained negative during the entire follow-up of 21 months after liver

transplantation. Combination therapy with entecavir plus tenofovir may prevent

post-liver transplant hepatitis B recurrence even without HBIg maintenance

therapy. This case illustrates that combination oral antiviral therapy might

substitute for HBIg as indefinite prophylactic regimen due to profound antiviral

efficacy and low risk of viral resistance. Efficacy and safety must be further

investigated in randomized controlled trials.