Ask the Experts - Lung Transplantation in Hepatitis B Virus Carrier?
Ask the Experts - Lung Transplantation in Hepatitis B Virus Carrier?
I seek your advice on a single lung transplantation patient who is a hepatitis B virus (HBV) carrier. Is it necessary to administer lamivudine postoperatively, and if so what is the dosage and duration of usage?
Nan-Yung Hsu, MD
There is now much literature to attest to the utility of lamivudine for HBV infection. There is not however, much literature about the natural history of HBV in a carrier who receives a lung transplant. Indeed, HBV infection has previously been regarded as a contraindication to lung transplantation. How the new antiviral medications will influence this recommendation remains uncertain. What is clear is that if a patient who is a carrier of HBV (HbsAg+) is exposed to significant immunosuppression (post-lung transplantation), the chance of HBV becoming more active and progressive is high. This is borne out by a recent retrospective review of heart transplant recipients who were HbsAg+ prior to transplantation. In this cohort of 30 patients, 37% developed evidence of active hepatic inflammation or cirrhosis and 5 of the 9 deaths in the group were felt to be related to HBV infection. After consultation with one of my transplant hepatology colleagues, although currently unproven in clinical trials, we would have no hesitancy to suppress HBV in this patient using the medication that is associated with many fewer side effects than interferon. This medication, as eluded to in the question, would be lamivudine. The accurate dose is not known, but we would use the standard dose for HBV (100 mg daily). As to the question of duration, once again this is unknown, but certainly it should be used in the periods of greatest immunosuppression and quite likely lifelong, with the caveat that resistance may become a problem.
I seek your advice on a single lung transplantation patient who is a hepatitis B virus (HBV) carrier. Is it necessary to administer lamivudine postoperatively, and if so what is the dosage and duration of usage?
Nan-Yung Hsu, MD
There is now much literature to attest to the utility of lamivudine for HBV infection. There is not however, much literature about the natural history of HBV in a carrier who receives a lung transplant. Indeed, HBV infection has previously been regarded as a contraindication to lung transplantation. How the new antiviral medications will influence this recommendation remains uncertain. What is clear is that if a patient who is a carrier of HBV (HbsAg+) is exposed to significant immunosuppression (post-lung transplantation), the chance of HBV becoming more active and progressive is high. This is borne out by a recent retrospective review of heart transplant recipients who were HbsAg+ prior to transplantation. In this cohort of 30 patients, 37% developed evidence of active hepatic inflammation or cirrhosis and 5 of the 9 deaths in the group were felt to be related to HBV infection. After consultation with one of my transplant hepatology colleagues, although currently unproven in clinical trials, we would have no hesitancy to suppress HBV in this patient using the medication that is associated with many fewer side effects than interferon. This medication, as eluded to in the question, would be lamivudine. The accurate dose is not known, but we would use the standard dose for HBV (100 mg daily). As to the question of duration, once again this is unknown, but certainly it should be used in the periods of greatest immunosuppression and quite likely lifelong, with the caveat that resistance may become a problem.
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