1. Nefrologia dei trapianti
HEPATITIS B INFECTION
IN A POPULATION OF RENAL TRANSPLANT RECIPIENTS. A SINGLE CENTER EXPERIENCE.
A. Tsalouchos, M. Zanazzi, A.L. Zignego, L. Moscarelli, P. Carta, A. Larti, L. Caroti,
N. Paudice, L. Di Maria, A. Mjeshtri, M. Salvadori and E. Bertoni.
Nefrologia dei trapianti
AOU Careggi Firenze.

2. OBJECTIVES
The objective of this study was to investigate the long-term outcome in RTRs with reactivation of hepatitis B and the impact of antiviral treatments before the era of effective antiviral agents and in the era of nucleoside analogues, focusing on patient and graft survival and the management of drug resistance.

3. METHODS
We retrospectively reviewed the Long-Term clinical outcome and the impact of Antiviral Treatments of 18 inactive carriers (HBsAg+) before kidney transplantation and 7 occult carriers (HBsAg- , Anti-HBc +) with re-emergence of HBsAg (seroreversion ) after kidney transplantation.
The patients included in the study have undergone kidney transplantation from 1989 to 2010, with follow-up median duration of 8 years.

4. (Before the era of effective antiviral agents)
RESULTS
(Before the era of effective antiviral agents)
4 of the 18 HBsAg+ patients underwent kidney transplantation before 1996, when lamivudine was first available.
patients were treated with cyclosporin + steroids regimen and exclusion of azathioprine in the maintenance therapy.
3/4 (75%) of HBsAg+ RTRs developed a significant viremia ( > 20,000 IU/mL) (reactivation).
The median time for reactivation to develop was 13 months.

5. RESULTS (The use of Lamivudine)
17 (68%) of the 25 patients ( 12 HBsAg+ and 5 anti-HBc+) had received antiviral treatment with lamivudine as initial therapy, including 4 patients transplanted before 1996 and 13 patients after 1996.
The 13 patients transplanted after 1996 and 1 patient transplanted before 1996 were treated preemptively (HBV DNA positive) through the control of serum HBV DNA and ALT levels every 3 months.

6. RESULTS (The use of Lamivudine)
15/17 (88%) patients showed clearance of HBV DNA by 6 months ; and ALT normalization occurred in 82% (14/17).
8 of the 17 lamivudine-treated patients (47%) developed drug resistance at 4 years.
The patients who developed drug resistance continued the treatment with lamivudine, until the availability of alternative agents.

7. (Add-on therapy with adefovir in lamivudine-resistant RTRs)
RESULTS
(Add-on therapy with adefovir in lamivudine-resistant RTRs)
5 lamivudine-resistant patients were treated with add-on adefovir.
The virological response rate was of 80% (4/5), in median after 12 months, without virological breakthrough .

8. RESULTS (The use of Entecavir)
Currently we use prophylaxis with Entecavir for all HBsAg+ RTRs & preemptive treatment for all anti-HBc+ RTRs.
6 HBsAg+ RTRs receive prophylaxis with entecavir without the appearance of any virological reactivation.
2 Anti-HBc+ RTRs with reactivation after transplantation showed a virological response with entecavir treatment.

9. OUTCOME OF RTRs WITH HBV INFECTION.
Mortality after transplantation: The 8-year survival rate was 80% (5/25) , none of the mortalities were attributed to liver related complications.
Causes of death:
Infection (4)
Neoplasia (1)
Graft survival: The graft’s survival rate was 92% (2/25).
HBV infection had no influence on graft survival.

10. CONCLUSIONS
Treatment with nucleoside analogues confers long term survival benefit in RTRs with HBV infection.
We suggest that currently entecavir is preferable to any other treatment.

11. GRAZIE DELL’ ATTENZIONE !