Patients with hepatitis B should not be given low priority

George Webster, clinical research fellow. Eleanor Barnes, clinical research fellow. Andrew Burroughs, consultant physician and hepatologist. Geoffrey Dusheiko, professor of medicine.  Centre for Hepatology, Royal Free and University College Medical School, Royal Free Campus, London NW3 2PF

EDITOR - The editorial by Masterton on psychosocial selection of patients for liver transplantation was timely and informative.¹ Liver transplantation depends on public support for continued organ donation and state support in running a transplantation programme. It is vital that debate takes place concerning patient selection.

It is right that in assessing a patient's suitability for a transplant clinicians emphasise the prognosis after transplantation. We are therefore concerned that Masterton said that patients with chronic hepatitis B virus infection have a poor outcome following transplantation and should therefore, by implication, be given low priority for transplantation. In the past, recurrence of hepatitis B virus infection has been problematic after liver transplantation and has been associated with fibrosing cholestatic hepatitis, accelerated cirrhosis, and a three year survival of only 44% in those patients with reinfection of the graft.² However, the introduction of hepatitis B immunoglobulin,³ and then of lamivudine prophylaxis,⁴ has been shown to reduce considerably the replication of the hepatitis B virus after transplantation, and the rate of graft loss related to the hepatitis B virus.

Lamivudine treatment, either alone or in combination with hepatitis B immunoglobulin, has been shown to be associated with >97% patient survival after a median follow up of more than two years.⁵ Longer term follow up will confirm whether these considerably improved responses are maintained. The development of variants of the hepatitis B virus that are resistant to lamivudine presents a challenge, which it is hoped may be minimised with the development of other combinations of antiviral agents.

Nevertheless, the introduction of new treatments over the past five years has led to a greater improvement in medium term survival of patients given a transplant because of hepatitis B than in patients with any other single indication. Therefore, we do not believe that patients who need liver transplantation and whose liver disease is caused by hepatitis B virus infection should be given low priority.

George Webster , clinical research fellow. 
gwebster@rfc.ucl.ac.uk

Eleanor Barnes , clinical research fellow. 
Andrew Burroughs , consultant physician and hepatologist. 
Geoffrey Dusheiko , professor of medicine. 
Centre for Hepatology, Royal Free and University College Medical School, Royal Free Campus, London NW3 2PF

 

1.	Masterton G. Psychosocial factors in selection for liver transplantation. BMJ 2000; 320: 263-264 . (29 January.)
2.	Samuel D, Muller R, Alexander G, Fassati L, Ducot B, Benhamou JP, et al. Liver transplantation in European patients with the hepatitis B surface antigen. N Engl J Med 1993; 329: 1842-1847   .
3.	McGory RW, Ishitani MB, Oliveira WM, Stevenson WC, McCullough CS, Dickson RC, et al. Improved outcome of orthotopic liver transplantation for chronic hepatitis B cirrhosis with aggressive passive immunization. Transplantation 1996; 61: 1358-1364 .
4.	Grellier L, Mutimer D, Ahmed M, Brown D, Burroughs AK, Rolles K, et al. Lamivudine prophylaxis against reinfection in liver transplantation for hepatitis B cirrhosis. Lancet 1996; 348: 1212-1215 .
5.	Nery JR, Weppler D, Rodriguez M, Ruiz P, Schiff ER, Tzakis AG. Efficacy of lamivudine in controlling hepatitis B virus recurrence after liver transplantation. Transplantation 1998; 65: 1615-1621 .