Outcomes in patients who are hepatitis B surface antigen-positive before transplantation: An analysis and study using the Joint ISHLT/UNOS Thoracic Registry

Background: Hepatitis B surface antigenemia (HBsAg) has been considered at least a relative contraindication for heart transplantation, yet patients have undergone liver transplantation for hepatitis B-induced chronic liver disease, albeit with poorer results than for other liver diseases. The impact of asymptomatic hepatitis B infection on heart transplant outcome is not known. Methods: To examine this question? we queried the Joint International Society for Heart and Lung Transplantation/United Network of Organ Sharing Thoracic Registry for all patients undergoing heart transplantation who had been identified as positive for HBsAg before transplantation. We then sent a 4-question data instrument to the centers responsible for the identified patients. Seventy-eight patients were identified. Of the 78 data forms sent, 53 forms were returned with the requested data. Of the 53 data forms returned, the centers incorrectly identified 23 patients as positive for HBsAg, resulting in 30 patients who were confirmed as HBsAg positive and who served as the final cohort for this analysis. Results: The cohort included 24 males and 6 females, with a mean age of 46 +/- 16 years (range 0 to 68 years). Eleven patients had coronary artery disease, 14 had dilated cardiomyopathy, and 5 patients had a variety of other cardiac diseases. Of those tested at most recent follow-up, 20 of 25 patients continued to be positive for HBsAg, whereas 7 of 21 patients studied had converted and were hepatitis B serum antibody-positive. Approximately 37% of the patients had evidence of active hepatic inflammation or cirrhosis. We found a statistically significant correlation between positivity for hepatitis C antibodies and clinical liver disease (p = 0.0105). No difference in survival could be demonstrated between the study cohort and a reference heart transplant cohort, yet 5 of the 9 deaths were considered to be related to hepatitis B. Conclusions: These data demonstrate that clinical liver disease is common posttransplantation in HBsAg+ patients who presumably have no overt liver disease at the time of transplantation. Despite the inability to show a survival difference in this cohort, the fact that the majority of deaths were related to hepatitis B should suggest caution in accepting HBsAg+ patients for cardiac transplantation.