Liver Transplantation in Patients With Hepatitis B Virus Infection: Outcome in Asian Versus White Patients

Abstract

Previous studies have found that Asian patients transplanted for hepatitis B virus (HBV) infectionEarly studies of liver transplantation (LT) for hepatitis B reported rates of recurrent hepatitis B virus (HBV) infection of 75% and survival of 50% 2 years post-LT. 1,2 The use of hepatitis B immune globulin (HBIG) and/or lamivudine prophylaxis led to a significant reduction in recurrent HBV infection and improved survival in these patients. A study from Europe reported a recurrent HBV infection rate of 36% at 3 years with long-term use of HBIG. 1 Studies in the United States using higher doses of HBIG reported recurrent HBV infection rates of 11% to 19% at 2 years. 3,4 Lamivudine monotherapy decreased recurrent HBV infection rate to 10% to 29% at 1 year post-LT, 5,6 but recurrent HBV infection increased to 50% at 2 years because of selection of lamivudine resistant mutants. 7 Preliminary results suggest that a combination of lamivudine and HBIG may be more effective in preventing recurrent HBV infection. [8][9][10] Previous studies have found that recurrent HBV infection was related to HBV replication pre-LT and coinfection with hepatitis D (HDV). 2,11 Three early reports suggested that Asians who had LT for hepatitis B have impaired outcomes. The first study reported on 3 Asians who developed recurrent HBV infection within 2 months post-LT: all 3 died within 6 months. 12 A second report on 45 patients (16 Asians vs. 29 non-Asians) found that Asians had higher rates of recurrent HBV infection (72% vs. 32%, P Ͻ .05) and higher mortality rate post-LT (87% vs. 22%, P Ͻ .05). 13 A third study on 35 patients (15 Asians vs. 20 non-Asians) found that Asians had lower 1-year survival rate post-LT (59% vs. 94%, P Ͻ .05) but 5-year survival rates were similar (59% vs. 54%). 14 Poor 1-year survival rates among Asians were attributed to late referral and more advanced liver disease at transplantation. There were no differences in recurrent HBV infection rate (64% Asians vs. 50% non-Asians) or deaths related to recurrent HBV infection.A high percentage of patients with HBV infection listed for LT in North America are Asian. It is important to ascertain if Asians transplanted for hepatitis B have a worse outcome. We conducted a retrospective analysis of a large cohort of patients listed for LT for hepatitis B to compare the rates of pre-and post-LT survival rates and recurrent HBV infection in Asians and whites, and to identify factors that may account for any difference in their outcome. PATIENTS AND METHODSA retrospective survey was conducted in 20 LT centers across North America. Patients with hepatitis B listed for LT between January 1996 and June 1998 were included. Patients were categorized into whites (Hispanic and non-Hispanic) and Asians (Chinese, Indians, Japanese, Koreans, Pacific Islanders, and individuals born in Southeast Asian countries) and other races (American Indians including Alaskans, African Americans, etc). Baseline demographics; indications for LT; liver biochemistries; hepatitis B, C, and D serology; an...

Survival after liver transplantation: Is racial disparity inevitable?

“…25 The comparison of pre-1994 and post-1994 data in our analysis further corroborates accumulating literature that post-OLT survival in recent Asian recipients is comparable to that in recipients of other racial categories. [26][27][28] As a proof of principle, our data, although put together from different databases from different time periods, indicate that OLT recipients of a minority race, especially the African race, should not necessarily be expected to have poorer survival than Caucasians. Although recipient race in and of itself may not be a direct predictor of poor outcome after liver transplantation, socioeconomic factors that correlate with minority race may explain previous observations that have shown such an association.…”

Liver transplantation outcomes among Caucasians, Asian Americans, and African Americans with hepatitis B

“…Another study of 15 Asians and 20 non‐Asians did not observe any difference in HBV recurrence rates between the 2 groups 7. A third study of 70 Asians and 99 whites reported similar rates of HBV recurrence: 11% versus 12% 8. In the current study, the probability of HBV recurrence 4 years post‐transplant was 19% among Caucasians, 7% among Asian Americans, and 6% among African Americans ( P = 0.043) despite similar HBeAg and HBV DNA status (at listing and at transplant), use of antiviral therapy pre‐transplant, occurrence of virological breakthrough/confirmed genotypic resistance to antiviral therapy pre‐transplant, and use of antiviral and HBIG prophylaxis post‐transplant.…”

“…Studies conducted after the introduction of hepatitis B immune globulin (HBIG) and lamivudine were more encouraging. A retrospective study of 70 Asians and 99 whites transplanted in the late 1990s found that post‐OLT survival and HBV recurrence were comparable between the 2 groups 8. Similarly, an analysis of the UNOS database of all adult patients transplanted for HBV between 1997 and 2002 found that post‐OLT survival of Asians was similar to that of other races 9.…”

Outcome of liver transplantation for hepatitis B in the United States

“…A subsequent report from a different center reported a lower 1‐year survival for Asian recipients compared with non‐Asians, although 5‐year survival probability was comparable 30. The most recent data came from a multicenter study that compared 124 Asian patients with 171 white patients 31. There was no difference between the two races in survival up to 2 years.…”