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Reply: Donor vaccination: Is it necessary to prevent HBV recurrence after living donor liver transplantation?

We appreciate the interest generated by the concept of adoptive immunity. The ultimate proof of the engraftment of donor lymphocytes would come from bone marrow studies, which we did not perform in this trial. However, the fact that engraftment does occur is quite evident from the fact that 19 of 75 patients developed significant antibody titers. Fourteen of these 17 patients had spontaneous antibody production, whereas the other 5 patients had antibody production as a response to vaccination more than 6 months after transplantation. There are other facts that underline the durability of engraftment. All the patients who developed significant antibody titers maintained titers greater than 10 mIU/mL over a median follow-up period of 17 months (range 5 6-70 months). Moreover, even the patients who did not form significant antibody titers did clear hepatitis B surface antigen, and they maintained a seronegative status throughout the follow-up. Sixty-six of the 75 patients in our cohort cleared hepatitis B surface antigen without significant recurrence over a long period of time (the actuarial probability of clearance was 92% at 2 years). This high seroclearance rate has not been documented in nontransplant patients with chronic hepatitis B. As for the other queries from Jiang et al., first, we did not systematically study the donor antibody response during the study period. However, this is being done in a follow-up trial. Second, most of the recipients received blood and blood products; we agree that this may have been contributory. Third, double-dose vaccination is very safe. None of the donors had any adverse events due to vaccination. Fourth, the low HBV DNA count before transplantation was deliberate. We actually postponed many elective transplants so that we could administer oral antivirals for at least 4 to 6 weeks to bring down DNA counts.