Volume 12, Issue 1 , Pages 84-94, January 2006
Extended Lamivudine Therapy against Hepatitis B Virus Infection in Hematopoietic Stem Cell Transplant Recipients
Article Outline
- Abstract
- Introduction
- Patients and methods
- Results
- Baseline Characteristics of HSCT Recipients Receiving Lamivudine Therapy
- Efficacy of Lamivudine Therapy
- Initial Response
- Maintained or End-of-Treatment Response and Breakthrough during Extended Therapy
- Chronological Detection of YMDD Mutations
- Sustained Response and Recurrence after Discontinuation of Therapy
- Lamivudine Therapy and HBV Reactivation Hepatitis after Transplantation
- Discussion
- Acknowledgments
- References
- Copyright
Abstract
Lamivudine has demonstrated efficacy in the treatment and prevention of hepatitis B virus (HBV) reactivation after hematopoietic stem cell transplantation (HSCT). However, most of these studies involved short durations of prophylaxis, so there is significant concern regarding lamivudine resistance in these patients. Between March 1984 and November 2002, 71 HBV surface antigen–positive HSCT recipients, including a subgroup of 16 who received pretransplantation lamivudine therapy, which was continued into the posttransplantation period to prevent reactivation hepatitis, were enrolled onto our study. The efficacy of lamivudine therapy was first evaluated for the subgroup of 16 patients in terms of treatment response, lamivudine resistance, and viral recurrence after discontinuation by using virologic assays. Efficacy was then evaluated for all patients in terms of the hazards of lamivudine therapy for reactivation hepatitis after transplantation. During a median lamivudine therapy period of 73 weeks (range, 19-153 weeks), the initial response showed a median reduction of 2.54 log10 in serum HBV DNA (−0.28 to 6.72 range). Lamivudine-resistant mutations were detected in 10 (63%) of 16 patients during therapy, and 1 (12%) of 16 patients finally developed a viral breakthrough. At a median follow-up of 30 months after discontinuation, 3 (27%) of 11 cases had recurrence of HBV infection. Despite the emergence of the mutations, no deaths were due to HBV reactivation or severe cases of hepatitis. In the Cox proportion regression model regarding reactivation hepatitis after transplantation of all enrolled patients, lamivudine therapy was found to be the only favorable factor for the event, with a hazard ratio of 0.122 (95% confidence interval, 0.016-0.908; P = .040). In conclusion, extended lamivudine therapy is safe and effective for the prevention of HBV reactivation in an HSCT setting and significantly decreases reactivation hepatitis after transplantation.
Key words: Hematopoietic stem cell transplantation , Hepatitis B virus , Lamivudine , Prophylaxis , Reactivation
Introduction
The pyrimidine nucleoside analogue lamivudine, a negative enantiomer of 3-thiacytidine, has successfully rescued life-threatening hepatitis B virus (HBV) reactivations in several reported cases after intensive chemotherapy [1, 2, 3] and hematopoietic stem cell transplantation (HSCT) [4, 5, 6, 7]. Furthermore, lamivudine is well tolerated and can be used to prevent subsequent reactivations, thus allowing completion of chemotherapy and subsequent HSCT [6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17]. Therefore, lamivudine can be administered before transplantation to hepatitis B surface antigen (HBsAg)–positive HSCT recipients who have demonstrated reactivation of HBV during previous courses of chemotherapy. Lamivudine therapy can be extended into the posttransplantation period, particularly to cover periods of increased immunosuppression that may be required to treat exacerbations of graft-versus-host disease (GVHD) or if salvage therapy is used to treat relapse [6, 7, 8, 9, 10, 11]. However, most of these studies described short durations of prophylaxis, and there is significant concern regarding the potential of lamivudine resistance in such patients.
HBV infection is endemic in Taiwan: up to 14% of its HSCT recipients are HBsAg positive [18]. Indeed, posttransplantation HBV reactivation results in significant complications and deaths in these HSCT recipients [19, 20, 21, 22]. Lamivudine became available at our institution in 1999 and was administered to HSCT recipients during the peritransplantation period. In this study, the efficacy of lamivudine therapy was initially evaluated, in terms of treatment response, lamivudine resistance, and viral recurrence after discontinuation, by the use of virologic assays for a subgroup of 16 HBsAg-positive HSCT recipients who received lamivudine therapy after transplantation to prevent HBV reactivation. Efficacy was subsequently evaluated for all HBsAg-positive recipients in terms of the hazards of lamivudine therapy for reactivation hepatitis after transplantation.
Patients and methods
Study Population
Between March 1984 and November 2002, 85 (16%) of 532 HBsAg-positive patients underwent HSCT in our institution [20, 21, 22]. With the exception of 7 with hepatitis C virus coinfection and another 7 with a follow-up of <2 months after transplantation, all remaining 71 recipients were enrolled onto the study, including a subgroup of 16 patients who received lamivudine to prevent HBV reactivation hepatitis after transplantation since 1999. The efficacy of lamivudine therapy was evaluated for the subgroup with lamivudine by using different virologic assays in terms of treatment response, lamivudine resistance, and viral recurrence after discontinuation. The effect of lamivudine therapy and other factors on HBV reactivation hepatitis after transplantation was analyzed for all 71 HBsAg-positive patients by using a Cox proportion regression model. The study was approved by the institutional review board of our institution. Follow-up of patients continued until February 2005.
HSCT Method and Lamivudine Therapy
In our institution, preparative regimens including total body irradiation (TBI) were administered to recipients with severe aplastic anemia and acute lymphoid leukemia, and those without TBI were administered to patients with myeloid leukemia and lymphoma. In vitro purging was not performed. The regimen for acute GVHD prophylaxis included a short course of methotrexate and cyclosporin A. The dose of cyclosporin A was decreased by 5% weekly until 6 months after transplantation. Reduced-intensity fludarabine-based regimens were administered to allogeneic recipients aged >45 years in 2000, in whom only cyclosporin A was used as prophylaxis of acute GVHD. With the exception of patients who received HSCT in the early 1980s, all recipients received granulocyte colony-stimulating factor to support engraftment. For cytomegalovirus (CMV) infection, preemptive therapy rather than primary prophylaxis was administered at the onset of clinical symptoms accompanied by positive anti-CMV immunoglobulin (Ig)M, qualitative polymerase chain reaction (PCR), or both. All recipients and donors were followed up with liver function tests and serologic tests (for hepatitis and CMV).
Lamivudine Therapy
Before the administration of lamivudine therapy, recipients and donors did not receive antiviral therapy against HBV, intravenous immunoglobulin, or HBV vaccinations within 12 weeks of the transplantation. Since 1999, lamivudine therapy (100 mg/d orally) was commenced in our HBsAg-positive HSCT recipients before transplantation, including those with no previous events of HBV reactivation hepatitis before transplantation (ie, primary prophylaxis) or those had already received lamivudine during conventional chemotherapy because of HBV reactivation hepatitis (ie, secondary prophylaxis). Therapy was extended into the posttransplantation period to prevent HBV reactivation. Discontinuation of lamivudine therapy after transplantation was considered when recipients satisfied all of the following criteria: (1) normal biochemical liver function tests, (2) remitted underlying disease with a low risk of relapse, and (3) no use of immunosuppressive medications or their use at maintenance dosages for >3 months. Sera collected before, during, and after therapy were stored at −20°C for use in virologic assays. Between March 2000 and November 2002, 16 patients underwent HSCT and received lamivudine as described previously. During the same period, 2 of 5 HBsAg-positive recipients who were not given lamivudine therapy according to the described schedule received it as rescue medication until the time of reactivation hepatitis after transplantation.
Assays
Biochemical liver function tests and serology tests of viral hepatitisLiver function tests, including alanine aminotransferase (ALT), aspartate aminotransferase, alkaline phosphate, γ-glutamyl transferase, and total bilirubin (TB), and serology tests of hepatitis viruses A, B, C, and D were performed as previously described [19, 20, 21, 22]. The values of normal ranges were <40 IU/L for ALT and <1.6 mg/dL for TB.
HBV DNA assaysViral DNA was extracted from 200 μL of serum by using the High Pure Viral Nucleic Acid Kit (Roche Molecular Biochemicals, Indianapolis, IN) according to the manufacturer’s recommendations. DNA was dissolved in 50 μL of elution buffer for subsequent tests.
The serum HBV DNA value was semiquantitatively measured by dot-blot hybridization by using a phosphorus 32–labeled HBV DNA probe (Bethesda Research Laboratories, Bethesda, MD) before 2000 [21] and then quantitatively by real-time PCR assay after 2000. Real-time PCR was performed by the LightCycler instrument (Roche Molecular Biochemicals, Mannheim, Germany), with the procedures slightly modified from those previously described [23]. PCR primers used in the amplification reaction were as follows: sense, 5′-GATGTGTCTGCGGCGTTTTA-3′, and anti-sense, 5′-CTGAGGCCCACTCCCATA-3′. The detection limit was 102 copies per milliliter. Because of its high sensitivity, only variations of more than 3-fold serum HBV DNA levels were considered to reflect significant changes, as recommended [24].
HBV Genotypes, Variants, and Mutations
The genotype was examined for the sera at baseline and was performed by PCR amplification with genotype-specific primers, thus allowing genotype-specific DNA bands on the gel electrophoresis identified [25].
Variants and mutations were examined by using sera stored at the serial follow-up; the nomenclature was based on workshop recommendations [26]. Variants of the basal core promoter (A1762T/G1764A) and precore (G1896A) sites were determined by direct sequencing for PCR-amplified HBV DNA fragments covering these sites, as previously described [22, 27]. Detection of specific mutations in the tyrosine-methionine-aspartate-aspartate (YMDD) motif of HBV polymerase, including substitutions of methionine by valine or isoleucine (YVDD/YIDD, M550V/I for genotype B and C) [28], was done by the amplification-created restriction site analysis, as previously described [29]. The presence of YMDD mutations was confirmed by gel electrophoresis and direct sequencing. This method detects the mutations when present in only 1% of the viral populations [29]. Sequencing of PCR-amplified products was performed as previously described [22].
Definitions
HBV reactivation hepatitis after transplantationHepatitis was defined as a serum ALT level >100 IU/mL on 2 consecutive determinations at least 5 days apart. Hepatitis severity was classified as icteric when clinical jaundice with the serum TB level >1.6 mg/dL was noted and was designated as fulminant when hepatic encephalopathy and irregular blood coagulation (prothrombin time prolonged for >10 seconds) were noted. With respect to the duration, the hepatitis was designated as acute (transient) if it lasted <6 months or as chronic (persistent) if it lasted >6 months [17, 21]. After other causes of posttransplantation hepatitis were excluded, including CMV infection, veno-occlusive disease, and acute and chronic GVHD, as previously described [30, 31, 32], HBV reactivation hepatitis was identified whenever there was laboratory evidence of viral reactivation. Because the assays used were not universal for all our recipients, virologic evidence of HBV reactivation in HBsAg-positive HSCT recipients included (1) the appearance of serum hepatitis B early antigen (HBeAg; from negative to positive), HBV DNA (by dot-blot hybridization), and/or anti-hepatitis B core IgM [21] and/or (2) a quantitative increase of serum HBV DNA to more than 10-fold that of the pre-exacerbation baseline [17]. Liver biopsy was performed, if possible, when the cause was not clear and the recipient had a low risk of bleeding or infection.
Efficacy of lamivudine therapyEfficacy was evaluated in terms of treatment response, viral breakthrough, and recurrence. Treatment response was initially assessed by using liver function tests, viral load assays, and specific antibody production [26]. A biochemical response was indicated by normal serum ALT levels, and a virologic response was indicated by the decline or maintenance of serum quantitative HBV-DNA levels and/or accompanying seroconversion of HBsAg, HBeAg, or both. Furthermore, according to the time course relative to lamivudine therapy, the response was further designated as initial (occurring within the first 6 months), maintained (at the time of last evaluation during extended therapy), end of treatment (at the time of discontinuing therapy), or sustained (6-12 months after discontinuing therapy) [26]. Along with a maintained or end-of-treatment response during lamivudine therapy, viral breakthrough was identified if there was a reappearance of serum HBV DNA of either a level >103 copies per milliliter (for recipients who had an undetectable serum HBV DNA [ie, <102 copies per milliliter] at the initial virologic response) or a >100-fold increase above the value at the initial virologic response (for recipients who did not have an undetectable serum HBV DNA level).
Statistical Analysis
Chi-squared or Fisher exact tests were used to compare the difference in events between different groups. Cox proportional hazards regression analyses using a forward stepwise selection procedure were used to estimate hazards (with 95% confidence intervals) for HBV reactivation hepatitis after transplantation, with adjustment for several independent factors, including the recipient’s sex, age, diagnosis (lymphoma versus nonlymphoma), presence of HBeAg, liver function tests just before HSCT, source of graft (autologous versus allogeneic), preparative regimen (TBI versus non-TBI), donor’s HBsAg status, and use of lamivudine therapy. Most of these factors were selected mainly according to findings from previous reports [21] and data availability at the time of analysis. Kaplan-Meier curves were used to estimate the cumulative hazards of HBV reactivation hepatitis after transplantation. P values <.05 were considered statistically significant. Statistical analyses were performed with SPSS version 10.0 (SPSS Inc., Chicago, IL).
Results
Baseline Characteristics of HSCT Recipients Receiving Lamivudine Therapy
The baseline characteristics of the 16 patients who received lamivudine therapy during the peritransplantation period are summarized in Table 1. Patient 10, with multiple myeloma, initially underwent autologous followed by allogeneic HSCT. Only 1 (14%) of 7 donors of allogeneic HSCT, the sibling for patient 11, was HBsAg positive. The remaining 6 donors (5 siblings and 1 unrelated donor) were HBsAg negative and anti–hepatitis B core IgG/anti–HBeAg positive. Twelve (75%) of 16 recipients started to receive lamivudine therapy as primary prophylaxis of HBV reactivation hepatitis, and the other 4 (25%) received it as rescue (n = 2) or secondary prophylaxis (n = 2). Therapy commenced at a median of 11 weeks (range, 0-62 weeks) before transplantation and extended into the posttransplantation period to prevent HBV reactivation.
Table 1. Characteristics of 16 HBsAg-Positive HSCT Recipients Treated with Lamivudine
| Virologic Parameters | Clinical Course with Lamivudine Therapy | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Patient No. | Age (y)/Sex | Diagnosis | HBV Reactivations before* or at the Time† of Lamivudine Therapy | Genotype | HBeAg | Variants of BCP/Precore | Serum HBV DNA (×105 Copies/mL) | Chemotherapy‡ | HSCT§ | GVHD∥ | Relapse | Duration of Lamivudine Therapy (wk) |
| Autologous | ||||||||||||
 1 | 40/M | AML | No | C | − | +/+ | 0.031 | No | Yes | No | No | 74 |
| 2 | 26/M | AML | Yes* | B | + | −/− | 3380.000 | No | Yes | No | Yes | 31 |
| 3 | 23/M | AML | No | B | − | +/− | 4.576 | Yes | Yes | No | No | 90 |
| 4 | 45/F | NHL | Yes—icteric* | B | − | +/− | 0.037 | Yes | Yes | No | No | 79 |
| 5 | 56/F | NHL | No | C | + | +/− | 5426.000 | Yes | Yes | No | No | 105 |
| 6 | 28/M | NHL | No | B | − | −/+ | 1568.000 | No | Yes | No | No | 36 |
| 7 | 25/M | NHL | Yes—icteric† | C | + | +/+ | 2509.000 | Yes | Yes | No | No | 19 |
| 8 | 50/M | NHL | No | B | + | +/+ | 9988.000 | Yes | Yes | No | No | 31 |
| 9 | 19/F | HD | No | B | + | −/− | 0.996 | Yes | Yes | No | No | 153 |
| 10 | 45/M | MM | No | B | − | −/+ | 1.671 | Yes | Yes | Yes | Yes | 97 |
| Allogeneic | ||||||||||||
| 11 | 42/M | AML | No | B | − | +/+ | 0.025 | Yes | Yes | Yes | No | 102 |
| 12 | 48/M | CML-BC | Yes† | B | − | −/+ | 5197.000 | No | Yes | Yes | Yes | 120 |
| 13 | 35/M | CML-CP | No | B | − | −/+ | 22.330 | No | Yes | Yes | No | 122¶ |
| 14 | 51/F | CML-CP | No | B | − | −/+ | 5.818 | No | Yes | Yes | No | 23 |
| 15 | 45/M | CML-CP | No | B | − | −/+ | 0.026 | No | Yes | Yes | No | 112 |
| 16 | 35/M | NHL | No | B | − | −/+ | 67.700 | Yes | Yes | No | Yes | 57 |
| Median | 41 (19-56) | Yes (4) | B/C = 13/3 | +/− = 5/11 | BCP (3), precore (7), both (4) | 14.072 (0.025-9988) | Yes (9) | Yes (16) | Yes (6) | Yes (4) | 73 (19-153) | |
| (range) | M/F = 12/4 | |||||||||||
‡ Lamivudine therapy given since pretransplantation chemotherapy. |
§ given just before HSCT. |
∥ given during the period of acute and/or chronic GVHD. |
¶ continued at the last follow-up in February 2005. |
Efficacy of Lamivudine Therapy
At the end of follow-up, the median duration of lamivudine therapy for 16 HSCT recipients was 73 weeks (range, 19-153 weeks), including 1 patient who continued therapy (Table 1). In the case of patient 10, with multiple myeloma, therapy was once discontinued according to the schedule at 62 weeks because of temporary disease remission after the initial autologous HSCT, but it was later re-started when the disease relapsed, and salvage chemotherapy and allogeneic HSCT were given (Table 1).
Initial Response
After lamivudine therapy, 2 (100%) of 2 recipients (patients 7 and 12; Table 1) who took lamivudine as the rescue medication for HBV reactivation hepatitis during chemotherapy achieved a rapid biochemical response. Other recipients had consistently normal liver function tests. In terms of the initial virologic response in all 16 recipients, there was a median maximal reduction of 2.54 log10 in the serum HBV DNA level (range, −0.28 to 6.72), including undetectable levels in 3 (19%) of 16 cases (Table 1). An insignificant increase (ie, variations less than 3-fold) was observed in 2 recipients (patients 1 and 4), who both had a low-titer baseline level (<104 copies per milliliter). Loss of HBsAg was seen in 1 (20%) of 5 recipients (patient 7) after 18 weeks of therapy, and temporary loss of HBsAg was seen in another patient (patient 11; 6%) after 32 weeks of therapy.
Maintained or End-of-Treatment Response and Breakthrough during Extended Therapy
Fourteen (88%) of 16 recipients achieved an end-of-treatment or maintained response at the time of discontinuation or at the last follow-up, respectively (Table 2). Two (12%) of 16 recipients (patients 1 and 15) were found to have HBV DNA breakthroughs after 57 and 27 weeks of therapy, respectively. In the case of patient 1 (Figure 1), the breakthrough was attributed to possible YMDD mutations and was accompanied by only a mild increase of serum ALT (60 IU/L; see “Chronological Detection of YMDD Mutations”). In the case of patient 15, the breakthrough was preceded by an episode of acute GVHD grade III (11 weeks after transplantation) and was possibly related to use of immunosuppressive agents rather than to mutations.
Table 2. Treatment Response of Lamivudine Therapy in 16 HBsAg-Positive HSCT Recipients
| Initial⁎ (n = 16) | Maintained/End of Treatment⁎ (n = 16) | Sustained⁎ (n = 11)† | |||||||
|---|---|---|---|---|---|---|---|---|---|
| YMDD Mutations | |||||||||
| Patient No. | Maximal HBV DNA Change (× Log10) | Biochemical‡ | Virological/Biochemical | Breakthrough | Virologic/Biochemical | Recurrence | Survival (mo) | Baseline | During |
| Autologous | |||||||||
| 1 | 0.26 | NA | No | Yes | + | + | Yes | No | 43.7§ |
| 2 | −2.70 | NA | Yes | No | − | − | NA† | NA† | 6.8∥ |
| 3 | −1.73 | NA | Yes | No | + | + | Yes | No | 44.3§ |
| 4 | 0.28 | NA | Yes | No | − | + | No | Yes | 54.1§ |
| 5 | −2.45 | NA | Yes | No | − | − | No | Yes | 48.1§ |
| 6 | −5.59 | NA | Yes | No | − | − | Yes | No | 39.0§ |
| 7 | −4.55 | Yes | Yes | No | − | − | Yes | No | 59.7§ |
| 8 | −3.39 | NA | Yes | No | − | − | NA† | NA† | 2.2¶ |
| 9 | −1.12 | NA | Yes | No | − | + | No | Yes | 36.6§ |
| 10 | −2.62 | NA | Yes | No | − | + | NA† | NA† | 36.9∥ |
| Allogeneic | |||||||||
| 11 | −1.40# | NA | Yes | No | − | + | Yes | No | 30.0§ |
| 12 | −6.72# | Yes | Yes | No | − | + | Yes | No | 39.3§ |
| 13 | −4.35# | NA | Yes | No | − | + | NA† | NA† | 28.0§ |
| 14 | −1.43 | NA | Yes | No | − | − | Yes | No | 39.8§ |
| 15 | −0.72 | NA | No | Yes | + | + | Yes | No | 36.5§ |
| 16 | −3.30 | NA | Yes | No | − | + | NA† | NA† | 5.8∥¶ |
| No. of patients evaluated (%) | Median, −2.54 (range, −6.72 to 0.28) | 2/2 (100) | 14/16 (88) | 2/16 (12) | 3/16 (19) | 10/16 (63) | 8/11 (73) | 3/11 (27) | Alive/dead = 12/4 |
⁎ Definitions as described in “Patients and Methods.” |
† Excluding 5 patients who continued lamivudine therapy at their last follow-up. |
‡ Evaluation only for the 2 recipients with hepatitis due to HBV reactivation at the time of lamivudine therapy. |
§ Alive at last follow-up. |
∥ Died of relapse. |
¶ Died of sepsis. |
# Once achieved an undetectable serum level (ie, 102 copies per milliliter). |
Figure 1.
YMDD mutation–associated breakthrough during extended lamivudine therapy. A 40-year-old HBsAg-positive man with acute myeloid leukemia (patient 1 in Table 1, Table 2), who received lamivudine between 1 week before transplantation and 73 weeks after transplantation, had an HBV DNA (•) breakthrough and an ALT (○) increase 56 weeks after transplantation (ie, 57 weeks of lamivudine therapy). With an amplification-restriction detection method [29], PCR products of wild-type (YMDD) and mutant-type (YVDD) viruses were 111 and 86 base pairs (bp), respectively. In the lane below, of gel electrophoresis, the mutation in fact preexisted in the mixture of wild-type and mutant-type viral population before lamivudine therapy (14 weeks before transplantation) and became dominant during therapy (72 weeks after transplantation). After discontinuation of therapy, the mutant type was soon taken over by the wild type (85 weeks after transplantation). Shaded block, period of lamivudine therapy; ○, value of ALT (IU/L); •, value of log10 HBV DNA (copies per milliliter).
Chronological Detection of YMDD Mutations
Detection of YMDD mutations was initially performed only on serum samples taken at the time therapy was discontinued or at the end of the study period; a chronological analysis during lamivudine therapy was planned for recipients with detected mutations. However, mutations were found in the sera of several recipients before therapy, and, therefore, chronological analysis was performed for all recipients. A YMDD mutation, YVDD, was detected in the sera of 3 (19%) of 16 recipients before the initiation of therapy (Table 2). These data were further supported by the finding that, of 18 HBsAg-positive patients who did not receive lamivudine therapy before 1999, sera from 3 (17%) patients was shown to carry the variants, including 2 (25%) of 8 HSCT recipients after transplantation and 1 (10%) of 10 with different hematologic malignancies. During lamivudine therapy, 10 (63%) of 16 cases had mutations detected at variable time points: YVDD in 9 and YIDD in 1 (Table 2). For the 7 patients with no preexisting mutations before therapy, mutations were first detected at a median of 28 weeks of therapy (range, 4-113 weeks). Most of these detected mutations were present within the wild-type viral population, as shown in the gel electrophoresis of patient 1 (Figure 1).
Sustained Response and Recurrence after Discontinuation of Therapy
Eleven recipients who discontinued lamivudine therapy were available for evaluation of sustained response. With a median follow-up of 30 months after discontinuation (range, 6-58 months), 8 (73%) of 11 recipients had sustained responses; however, 3 (27%) of 11 had viral recurrences (Table 2). Two patients (patients 5 and 9) only had HBV DNA recurrences; however, patient 4 developed icteric hepatitis 31 weeks after discontinuation, which resolved after reinitiation of lamivudine therapy (Figure 2). The occurrence of mutations during therapy did not alter the risk of viral recurrence after discontinuation (P = 1.00 by Fisher exact test).
Figure 2.
Late viral recurrence with icteric hepatitis manifested 31 weeks after discontinuation of lamivudine therapy. A 45-year-old HBsAg-positive woman with non-Hodgkin lymphoma (patient 4 in Table 1, Table 2), who had a previous episode of HBV reactivation hepatitis during pretransplantation chemotherapy (arrow), had received lamivudine since 20 weeks before transplantation to allow completion of subsequent chemotherapy and autologous HSCT. Therapy was discontinued 26 weeks after transplantation; however, viral recurrence with icteric hepatitis occurred 31 weeks later, with a surge of serum HBV DNA levels and the appearance of serum HBeAg and anti-HBc IgM. Hepatitis was resolved after reinitiation of lamivudine therapy. ○, value of ALT (IU/L); •, value of log10 HBV DNA (copies per milliliter).
Lamivudine Therapy and HBV Reactivation Hepatitis after Transplantation
With a median follow-up of 39 months (range, 2-216 months) after transplantation, 38 (54%) of the 71 HBsAg-positive recipients were found to have posttransplantation hepatitis, among whom 8 (21%) of 38 had undergone liver biopsy to determine the cause. Twenty-nine (79%) of 38 cases were classified as acute/transient in terms of duration, and 23 (61%) of 38 were classified as icteric in terms of severity. With the exception of the cases attributed to acute GVHD (n = 4), chronic GVHD (n = 6), underlying diseases (n = 2), and undetermined causes (n = 2), 24 (24/38, 63% of all posttransplantation hepatitis; 24/71, 32% of all recipients) cases were identified as HBV reactivation hepatitis (Table 3).
Table 3. HBV Reactivation Hepatitis after Transplantation in 71 HBsAg-Positive HSCT Recipients
| HBV Reactivation Hepatitis after Transplantation (n = 22) | |||||
|---|---|---|---|---|---|
| Parameters | Recipients (n = 71), No. (%) | n (%) | Hazard Ratio⁎ | 95% CI⁎ | P Value⁎ |
| Sex | |||||
| Male | 44(62) | 10(46) | 0.571 | 0.247-1.322 | .191 |
| Female | 27(38) | 12(54) | 1 | ||
| Median age, y (range) | 33(9-60) | — | 0.969 | 0.933-1.007 | .101 |
| Diagnosis | |||||
| Lymphoma | 23(32)† | 7(32) | 0.996 | 0.406-2.443 | .992 |
| Nonlymphoma | 48(68)‡ | 15(68) | 1 | ||
| HBeAg | |||||
| Positive | 29(41) | 9(41) | 0.958 | 0.409-2.243 | .921 |
| Negative | 42(59) | 13(59) | 1 | ||
| ALT before transplantation§ | |||||
| Abnormal | 9(13) | 3(14) | 1.232 | 0.364-4.165 | .737 |
| Normal | 62(87) | 19(86) | 1 | ||
| Source of graft | |||||
| Allogeneic | 43(61) | 17(77) | 2.545 | 0.936-6.917 | .067 |
| Autologous | 28(39) | 5(23) | 1 | ||
| Use of TBI | |||||
| Yes | 32(45) | 13(59) | 2.074 | 0.884-4.867 | .094 |
| No | 39(55) | 9(41) | 1 | ||
| Allogeneic donor’s HBsAg¶ | |||||
| Positive | 16(37) | 6(35) | 1.154 | 0.425-3.135 | .778 |
| Negative | 27(63) | 11(65) | 1 | ||
| Lamivudine therapy | |||||
| With | 16(23) | 1(4) | 0.122¶ | 0.016-0.908¶ | .040¶ |
| Without | 55(77) | 21(96) | 1 | ||
⁎ By a simple Cox proportion regression analysis of each factor. |
† Including non-Hodgkin lymphoma (n = 21) and Hodgkin disease (n = 2). |
‡ Including acute myeloid leukemia (n = 16), acute lymphoid leukemia (n = 9), chronic myeloid leukemia (n = 15), severe aplastic anemia (n = 5), multiple myeloma (n = 2), and paroxysmal nocturnal hemoglobinuria (n = 1). |
§ Within 2 weeks before transplantation for 43 allogeneic HSCT recipients. |
¶ Same as the values derived from the Cox proportion regression analysis of all factors in this table. |
HBV reactivation hepatitis had a median onset time of 4.5 months after transplantation (range, 0.5-13.5 months). Twenty (83%) of 35 presented as acute (transient) hepatitis and 16 (67%) of 24 as icteric hepatitis, including 7 cases of fulminant hepatitis. Regarding HBV reactivation hepatitis after transplantation, the univariate and multivariate Cox proportion hazards regression analysis with several independent factors showed that lamivudine therapy was the only statistically significant factor, with a hazard ratio of 0.122 (with versus without lamivudine therapy; 95% confidence interval, 0.016-0.908; P = .040; Table 3 and Figure 3). There was no death due to HBV reactivation hepatitis for recipients of lamivudine therapy, in contrast to 6 deaths for those without it (P = .174 by log-rank test). There was no difference in overall survival between those with and without lamivudine prophylaxis (P = .530 by log-rank test).
Figure 3.
Curve of cumulative hazards for HBV reactivation hepatitis after transplantation in HBsAg-positive HSCT recipients according to lamivudine therapy. Cox proportion hazards regression analysis adjusted by several independent factors showed that lamivudine therapy was the only statistically significant factor, with hazard ratio of 0.122 (with versus without lamivudine therapy; 95% confidence interval, 0.016-0.908; P = .040).
Discussion
Our study used virologic assays, including variants, mutations, and quantitative HBV DNA, to resolve some concerns regarding lamivudine therapy for HSCT recipients. Lamivudine therapy effectively suppresses viral replication through different clinical courses for HSCT recipients during the peritransplantation period, as shown by changes in serum HBV-DNA levels. The treatment response is not inferior to that for chronic hepatitis B [33, 34]. Data from our study show that responses are maintained, even in recipients who harbor HBV variants of precore and/or basal core promoter sites. The findings are significant because patients who harbor these variant viruses are at a higher risk of severe or fulminant hepatitis compared with patients with wild-type viruses [22, 35, 36, 37]. These variants account for 7% to 30% of HBV carriers worldwide, with an increasing prevalence in these hyperendemic areas [38, 39, 40].
The chronological detection of YMDD mutations in our study further clarifies prevailing concerns regarding the emergence of mutations and associated breakthrough during extended lamivudine therapy. With the high sensitivity of detection assay used in our study [29], a higher proportion (63%) of our patients were shown to have these mutations, mainly presenting as a mixture of wild- and mutant-type viral population, during extended lamivudine therapy. Furthermore, preexisting mutations were even shown in lamivudine-untreated sera from 6 (18%) of 34 HBsAg-positive patients, as seen in recent articles [41, 42, 43, 44]. These findings support the concept derived from clonal analysis of HBV quasispecies that most of the nucleotide and amino acid changes during lamivudine therapy were related to a shift of the dominant HBV strain within preexisting quasispecies [45]. Fortunately, with relatively shorter treatment durations, the mutation-associated breakthrough was low in our HSCT recipients, similar to that in patients who did not receive HSCT [46]. However, findings from our study and a previously reported case involving a biochemical breakthrough due to mutations after 9 months of lamivudine therapy [17] and the emergence of YMDD mutations during extended lamivudine therapy for HSCT recipients present a challenge that cannot be overlooked.
In agreement with 3 previous reports [16, 17, 47], a high rate of HBV DNA recurrence (even with hepatitis; 27%) after discontinuation of lamivudine therapy was found in our study. It is important to note that our study illustrated 1 case (patient 10) with late recurrence, 31 weeks after discontinuation. In fact, with further application of lamivudine therapy for HSCT recipients, a close follow-up for viral recurrence after discontinuation of therapy will become important.
Although somewhat limited by the relatively small number of patients, this single-institution study in an HBV-hyperendemic area provides direct evidence in support of prophylactic lamivudine therapy in HBsAg-positive HSCT recipients. Furthermore, because 67% of our patients received lamivudine as primary prophylaxis, our study further supports lamivudine therapy as primary prophylaxis in terms of its relative safety and efficacy. Lamivudine therapy can commence early in patients with evidence of accelerated HBV replication before the development of overt hepatitis; however, the capacity for early detection is usually limited by the cost and frequency of examinations during follow-up. In addition, lamivudine has been reported to fail as rescue medication for HBV reactivations in several cases after chemotherapy and in HSCT recipients [2, 3, 48, 49, 50, 51]. Because ethical reasons will further limit cohort clinical studies designed to investigate this issue, cumulative evidence, including data from this study, supports lamivudine use as primary prophylaxis in the HSCT setting [17]. In addition to the benefits of 1 year of lamivudine therapy for allogeneic HSCT recipients demonstrated in the study by Lau et al. [17], our study further supports extended lamivudine therapy in HSCT recipients for >1 year, especially for patients who commence therapy before transplantation and for those with complicated posttransplantation diseases. It is apparent that the benefit of being free from HBV reactivation seems to exceed the assault from lamivudine-associated HBV mutations.
In conclusion, extended lamivudine therapy for HSCT recipients during the peritransplantation period is effective in suppressing viral replications, thereby significantly decreasing posttransplantation hepatitis due to HBV reactivation in HBsAg-positive HSCT recipients. It is important for these recipients to receive close follow-up for breakthroughs during extended therapy and for recurrences after discontinuation.
Acknowledgments
We thank Kuo-I Hsiao and Chian-Ting Sun for preparing the stored sera and Shu-Chauo Chou for performing HBV assays. This study was supported by grants from the Taiwan Cancer Clinic Foundation and the Taipei Veterans General Hospital (VGH93-192).
References
- . Successful treatment with lamivudine for fulminant reactivated hepatitis B infection following intensive therapy for high-grade non-Hodgkin’s lymphoma . Ann Oncol . 1998;9:385–387
- Lamivudine in the treatment of hepatitis B virus reactivation during cytotoxic chemotherapy . J Med Virol . 1999;59:263–269
- . Lamivudine for the treatment of hepatitis B virus reactivation following chemotherapy for non-Hodgkin’s lymphoma . Br J Haematol . 2002;116:166–169
- . Lamivudine treatment for chronic replicative hepatitis B virus infection after allogeneic bone marrow transplantation . Bone Marrow Transplant . 1998;21:1267–1269
- Lamivudine treatment for reverse seroconversion of hepatitis B 4 years after allogeneic bone marrow transplantation . Bone Marrow Transplant . 2002;29:361–363
- . Successful long-term control with lamivudine against reactivated hepatitis B infection following intensive chemotherapy and autologous peripheral blood stem cell transplantation in non-Hodgkin’s lymphoma (experience of 2 cases) . Am J Hematol . 2002;70:60–63
- . Successful antiviral treatment for fulminant reactivated hepatitis B after autologous stem cell transplantation and prophylaxis during subsequent allogeneic stem cell transplantation . Ann Hematol . 2002;81:343–346
- . Prevention of hepatitis B flare-up during chemotherapy using lamivudine (case report and review of the literature) . Ann Hematol . 1999;78:247–249
- . Lamivudine for the prevention of hepatitis B virus reactivation during autologous stem cell transplantation. A case report . Haematologica . 2000;85:327–329
- Lamivudine allows completion of chemotherapy in lymphoma patients with hepatitis B reactivation . Br J Haematol . 2000;108:394–396
- . Lamivudine therapy for a hepatitis B surface antigen (HBsAg)-positive leukemia patient receiving myeloablative chemotherapy and autologous stem cell transplantation . Bone Marrow Transplant . 2000;26:1243–1245
- A possible role for lamivudine as prophylaxis against hepatitis B reactivation in carriers of hepatitis B who undergo chemotherapy and autologous peripheral blood stem cell transplantation for non-Hodgkin’s lymphoma . Bone Marrow Transplant . 2001;27:433–436
- . Primary prophylaxis with lamivudine of hepatitis B virus reactivation in chronic HbsAg carriers with lymphoid malignancies treated with chemotherapy . Br J Haematol . 2001;115:58–62
- Efficacy of lamivudine to prevent hepatitis reactivation in hepatitis B virus-infected patients treated for non-Hodgkin lymphoma . Blood . 2002;99:724–725
- . Lamivudine therapy for prevention of immunosuppressive-induced hepatitis B virus reactivation in hepatitis B surface antigen carriers . Blood . 2002;100:391–396
- Limited efficacy of lamivudine against hepatitis B virus infection in allogeneic hematopoietic stem cell transplant recipients . Transplantation . 2002;73:812–815
- Preemptive use of lamivudine reduces hepatitis B exacerbation after allogeneic hematopoietic cell transplantation . Hepatology . 2002;36:702–709
- . Hepatitis B virus infection and chronic liver disease in Taiwan . Acta Hepatogastroenterol (Stuttg) . 1978;25:423–430
- Changing of hepatitis B virus markers in patients with bone marrow transplantation . Transplantation . 1990;49:708–713
- Liver disease after bone marrow transplantation—the Taiwan experience . Transplantation . 1995;59:1139–1143
- Fulminant hepatitis is significantly increased in hepatitis B carriers after allogeneic bone marrow transplantation . Transplantation . 1999;67:1425–1433
- Detection of reactivation and genetic mutations of the hepatitis B virus in patients with chronic hepatitis B infections receiving hematopoietic stem cell transplantation . Transplantation . 2002;74:182–188
- Development and assessment of a novel real-time PCR assay for quantitation of HBV DNA . J Virol Methods . 2002;103:201–212
- . Molecular diagnosis of viral hepatitis . Gastroenterology . 2002;122:1554–1568
- . Rapid and specific genotyping system for hepatitis B virus corresponding to six major genotypes by PCR using type-specific primers . J Clin Microbiol . 2001;39:362–364
- . Management of hepatitis B (2000—summary of a workshop) . Gastroenterology . 2001;120:1828–1853
- . Different hepatitis B virus genotypes are associated with different mutations in the core promoter and precore regions during hepatitis B e antigen seroconversion . Hepatology . 1999;29:976–984
- Nomenclature for antiviral-resistant human hepatitis B virus mutations in the polymerase region . Hepatology . 2001;33:751–757
- Emergence and takeover of YMDD motif mutant hepatitis B virus during long-term lamivudine therapy and re-takeover by wild type after cessation of therapy . Hepatology . 1998;27:1711–1716
- . Venocclusive disease of the liver after bone marrow transplantation (diagnosis, incidence, and predisposing factors) . Hepatology . 1984;4:116–122
- Clinical manifestations of graft-versus-host disease in human recipients of marrow from HLA-matched sibling donors . Transplantation . 1974;18:295–304
- Chronic graft-versus-host syndrome in man. A long-term clinicopathologic study of 20 Seattle patients . Am J Med . 1980;69:204–217
- A one-year trial of lamivudine for chronic hepatitis B . N Engl J Med . 1998;339:61–68
- . Efficacy of long-term lamivudine monotherapy in patients with hepatitis B e antigen-negative chronic hepatitis B . Hepatology . 2000;32:847–851
- Fulminant hepatitis B (induction by hepatitis B virus mutants defective in the precore region and incapable of encoding e antigen) . Gastroenterology . 1991;100:1087–1094
- . Allogeneic bone marrow transplantation for a patient complicated by chronic hepatitis due to precore mutant hepatitis B virus (failure of management with interferon-alpha therapy) . Am J Hematol . 1997;54:344–345
- High hepatitis B virus (HBV) DNA viral load as the most important risk factor for HBV reactivation in patients positive for HBV surface antigen undergoing autologous hematopoietic cell transplantation . Blood . 2002;99:2324–2330
- . Secular trend of age-specific prevalence of hepatitis B surface and e antigenemia in pregnant women in Taiwan . J Med Virol . 2003;69:466–470
- . Hepatitis B e antigen-negative chronic hepatitis B in Hong Kong . Hepatology . 2000;31:763–768
- . Hepatitis B e antigen-negative chronic hepatitis B . Hepatology . 2001;34:617–624
- . Detection of YMDD motif mutations in some lamivudine-untreated asymptomatic hepatitis B virus carriers . J Hepatol . 2001;34:584–586
- Detection of YMDD mutant using a novel sensitive method in chronic liver disease type B patients before and during lamivudine treatment . J Hepatol . 2002;37:259–265
- Occult HBV infection and YMDD variants in hemodialysis patients with chronic HCV infection . J Hepatol . 2003;38:506–510
- . Lamivudine resistant occult HBV (implications for public health?) . J Hepatol . 2003;38:526–528
- . Hepatitis B virus variants in patients receiving lamivudine treatment with breakthrough hepatitis evaluated by serial viral loads and full-length viral sequences . Hepatology . 2001;34:583–589
- . Course of virologic breakthroughs under long-term lamivudine in HBeAg-negative precore mutant HBV liver disease . Hepatology . 2002;36:219–226
- . Reactivation of hepatitis B e antigen-negative chronic hepatitis B in a bone marrow transplant recipient following lamivudine withdrawal . Can J Gastroenterol . 2001;15:599–603
- . Failure of lamivudine therapy for chemotherapy-induced reactivation of hepatitis B . Am J Gastroenterol . 2001;96:1651–1652
- . Lamivudine treatment failure in preventing fatal outcome of de novo severe acute hepatitis B in patients with haematological diseases . J Hepatol . 2001;35:823–826
- Fatal reactivation of hepatitis B virus following cytotoxic chemotherapy for acute myelogenous leukemia (fibrosing cholestatic hepatitis) . Eur J Haematol . 2002;69:101–104
- Prophylaxis against chemotherapy-induced reactivation of hepatitis B virus infection with lamivudine . J Clin Gastroenterol . 2003;37:68–71
PII: S1083-8791(05)00629-4
doi:10.1016/j.bbmt.2005.09.001
© 2006 American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.
Volume 12, Issue 1 , Pages 84-94, January 2006
