VIRAL hepatitis in solid organ transplantation other than liver

Abstract

Transplantation is the best treatment for end-stage organ failure. Hepatitis virus infections, mainly hepatitis B virus (HBV) and hepatitis C virus (HCV) infections still constitute a major problem because they are common in allograft recipients and are a significant cause of morbidity and mortality after transplantation. Recently, hepatitis E virus infection has been added as an emergent cause of chronic hepatitis in organ transplantation. The prevalence of HBV and HCV infections has markedly decreased in patients who are candidates for transplantation since the introduction of screening, hygiene and prevention measures, including systematic screening of blood and organ donations, use of erythropoietin, compliance with universal hygiene rules, segregation of HBV-infected patients from non-infected patients and systematic vaccination against HBV. A liver biopsy is preferable to non-invasive biochemical and/or morphological tests of fibrosis to evaluate liver fibrosis before and even after transplantation. Treatment with entecavir or tenofovir is indicated in HBV-infected dialyzed patients who have moderate or severe disease (≥A2 or F2 on the Metavir scale) in preparation for renal transplantation. Due to the risks of severe reactivation, fibrosing cholestatic hepatitis or histological deterioration after transplantation, systematic use of nucleoside or nucleotide analogues shortly before or at the time of transplantation is recommended (tenofovir or entecavir are preferable to lamivudine) in all patients, whatever the baseline histological evaluation. In HCV-infected dialyzed patients who are not candidates for renal transplantation, the indication for antiviral therapy is limited to significant fibrosis (fibrosis ≥2 on the Metavir scale). Treatment must be proposed to all candidates for renal transplantation, whatever their baseline histopathology, and interferon-α should be used as monotherapy. After transplantation, interferon-α is contraindicated but may be used in patients for whom the benefits of antiviral treatment clearly outweigh the risks, especially that of allograft rejection. All cirrhotic patients, notably after solid organ transplantation, should be screened for hepatocellular carcinoma. Sustained suppression of necro-inflammation may result in regression of cirrhosis, which in turn may lead to decreased disease-related morbidity and improved survival. Finally, due to the high mortality after renal transplantation, active (namely without sustained viral suppression) cirrhosis should be considered a contraindication to kidney transplantation, but an indication to combined liver-kidney transplantation; on the contrary, inactive (namely with sustained viral suppression) compensated cirrhosis may permit renal transplantation alone. Organ transplantations other than kidney (cardiac or pulmonary transplantations) involve the same diagnosis and therapeutic issues.

Complications of Kidney Transplantation: Effects of Over-Immunosuppression

“…All patients should be vaccinated against HBV, preferably before beginning dialysis due to poorer immune response to the vaccine in dialysis and transplant patients [89]. Revaccination should occur when hepatitis B surface antibody titers fall below 10 mIU/mL [88].…”

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“…14,22 The most frequent extrahepatic complications are de novo or recurrent glomerular disease and new-onset diabetes mellitus. 1 Hepatitis C virus-related liver disease after kidney transplant The risk of developing posttransplant liver disease depends on the severity of the liver disease before transplant, liver pathology, coinfection with hepatitis B virus, and the immunosuppressive regimen.…”

“…Posttransplant liver disease includes fibrosing cholestatic hepatitis, liver cirrhosis, hepatocellular carcinoma, and hepatic failure. 14 Hepatitis C virus-positive kidney transplant recipients have an increased risk for development of posttransplant liver disease of approximately 7.14-fold. 22 It is considered the fourth most important cause of mortality after kidney transplant.…”

“…The use of immunosuppressive drugs could promote viral replication in hepatocytes and enhance the progression of liver disease or lead to reactivation of the HCV infection, which presents as acute hepatitis. [13][14][15] Controversy remains regarding what is the optimal immunosuppressive regimen for kidney transplant recipients with HCV infection. The use of induction therapy is not contraindicated in HCV-positive kidney transplant recipients.…”

Spontaneous hepatitis B surface antigen seroconversion after long lasting hepatitis B virus infection in a chronic hemodialysis patient

“…Some individuals will spontaneously clear HBsAg, which usually confers a good prognosis if there is no pre-existing hepatocellular carcinoma or cirrhosis by the time of HBsAg seroclearance 9 . Nowadays, there is an universal consensus that all HbsAgpositive candidates for kidney TX should receive antiviral therapy with nucleos(t)ide analogues shortly before or at the time of grafting in order to maintain undetectable serum HBV DNA 14 . Our patient refused to be treated with antiviral therapy when it became available, which rules out seroconversion due to antiviral therapy.…”