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Increasing applicability of liver transplantation for patients with hepatitis B–related liver disease

Liver transplantation in patients with hepatitis B has been under discussion for 20 years because of inferior results without reinfection prophylaxis; therefore, we analyzed our overall experience with liver transplantation in hepatitis B patients with immunoprophylaxis, particularly the influence of the available antiviral treatment in different periods. From 1988 to 2000, 228 liver transplants in 206 hepatitis B patients were performed. Indications were acute liver failure (10%), hepatitis B virus (HBV) cirrhosis alone (67%) or with hepatitis D virus (HDV) (13%), or hepatitis C virus (HCV) coinfection (7%). All patients received long‐term immunoprophylaxis (anti‐HBs > 100 U/L). HBV DNA–positive patients were treated before and after surgery with famciclovir or lamivudine since 1993 and 1996, respectively. Since 1993, antivirals also were used for HBV reinfection. The 1‐, 5‐, and 10‐year patient survival rates were 91%, 81%, and 73%. In patients with hepatocellular carcinoma (HCC) (60% 5‐year survival, P < .01) or HBV reinfection (69% 5‐year survival, P < .01) survival was significantly impaired. Those with HDV or HCV coinfection had a slightly better survival than with HBV monoinfection (P > .05, not significant). Preoperative positive HBV DNA (hybridization‐assay) test results were associated with a slightly impaired patient survival (78% 5‐year survival, P > .05, not significant versus DNA‐negative). Preoperative positive hepatitis B e antigen (HBeAg) predicted significantly worse survival (P < .05 versus negative HBeAg). Graft loss caused by reinfection was most frequent before the availability of antiviral drugs. Two‐year patient survival increased from 85% in era I (1988‐1993) to 94% in era III (1997‐2000, P < .05). The 2‐year recurrence rates in these 2 periods were 42% and 8% (P < .05). In conclusion, excellent long‐term results can be achieved in hepatitis B patients after liver transplantation with modern strategies, and survival rates are similar to other indications. Based on our experience, hepatitis B patients, including those with active viral replication, should not be excluded from liver transplantation.