IMMUNOPROPHYLAXIS IN HBS POSITIVE PATIENTS WITH LIVER-TRANSPLANTATION

Controversy surrounds the indication of liver transplantation in patients with hepatitis B virus infection. The major problem is the very high risk of infection of the graft. Some investigators have suggested that the presence of HBsAg is a contraindication to liver transplantation. Between February 1975 and December 1990, 178 HBs positive patients were transplanted at Paul Brousse Hospital in Professor H. Bismuth's Department, 137 for post hepatitis cirrhosis and 41 for fulminant hepatitis. Since April 1984 we have decided long term immunoprophylactic therapy for all patients with HBs infection. But only from August 1987 our supply of purified anti HBs immunoglobulin has been adequate to treat all our patients according to the following protocol 10.000 IU during the anhepatic phase, 10.000 IU immediately after intervention, 10.000 IU every day for the first 6 days, 10.000 IU when the anti HBs levels were under 150 IU/l. One hundred thirty-nine patients were treated by this method. 110 cleared HBs antigen from their sera and their liver were biologically and histologically free of B virus infection. 29 patients showed reappearance of HBs antigen in their sera and nearly all of them developped objective, histologically confirmed, graft lesions. These lesions are those of classical infection : acute hepatitis, active chronic hepatitis and cirrhosis. So 79 % of patients were successfully treated with a follow up of 45 months to 6 months. We also studied the pronostic,factors under treatment. The study shows: in the case of fulminant hepatitis, 93 % success versus 77 % in post hepatitis cirrhosis ; in the case of Delta surinfection, 94 % success versus 66 % with pure B infection; in the absence of HBVDNA in the patient's sera before transplantation, 92 % success versus 20 % in the presence of HBVDNA. For a better understanding of the overall results, the two following parameters have to be considered: - some patients relapsed after stopping their treatment, - some other patients, despite repositivation of HBs antigen in their sera showed a paradoxal good evolution. These considerations enable us to obtain - HBVDNA positive patients : 10 % success, - HBVDNA negative patients: - Fulminant hepatitis : 100 % success - B Delta post hepatitis cirrhosis : 100 % success - B post hepatitis cirrhosis : 92 % success.