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 peroperative 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 developed 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 prognostic 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 superinfection, 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.