Liver transplant candidates should be vaccinated against Hepatitis B Virus: an analysis into current status
Jones F, Braniff C, Boyle M, Iqbal M
National Liver Transplant Unit, St. Vincent’s University Hospital
Donor related infections remain a significant concern for solid organ transplant recipients. Approximately 30% of the world’s population have been infected with Hepatitis B virus (HBV). De novo HBV infection post transplant can occur if recipients receive a HBV core antibody positive (HBV cAb+) donor liver. Solid organ transplant recipients develop a more severe and rapidly progressive HBV infection, resulting in excessive morbidity and mortality in this population. Over a 3 year period 2 patients in the National Liver Transplant Unit (NLTU) received a HBV cAb+ donor liver necessitating lifelong treatment with viral suppressive therapy +/- Hepatitis B Immunoglobulin. This represents a significant financial burden with costs of up to €80,000 for the first year of treatment and up to €7000 per annum thereafter. Unvaccinated transplant candidates may refuse a HBV cAb+ donor liver, resulting in sub-optimal graft utilisation.
The Centre for Disease Control (CDC) recommends vaccination for all patients with Chronic Liver disease. The American Society for the Study Liver Disease (AASLD) recommends HBV vaccination in all patients prior to liver transplantation however this is not routinely carried out in many centres. We sought to ascertain the current HBV vaccination status of patients on the liver transplant waiting list and review our current approach to vaccination in this patient population.
The NLTU database was accessed for patients on the active liver transplant waiting list. HBV serology was reviewed and patients or their GP were contacted directly regarding their HBV vaccination status.
At the time of this survey, 39 patients were on the active liver transplant waiting list. Median age was 56 years. Underlying liver disease included PBC (2%), PSC (26%), ALD (23%), AIH (7%), NASH (5%), HCC (18%) and others (19%). The median MELD score of this group was 15. Only 3 patients (7%) were vaccinated against HBV. Of those not vaccinated, none were aware of the potential benefit of HBV vaccination.
We found very low HBV vaccination rates in a high risk population on the active liver transplant waiting list. De novo HBV infection in these patients has huge patient related and cost implications. We therefore recommend the introduction of routine HBV vaccination in this population. We recommend a high-dose, accelerated vaccination schedule which is associated with improved vaccine response rates in patients with chronic liver disease.