Post-liver transplant hepatitis B prophylaxis with intramuscular HBIG and lamivudine - report of 4 cases

Introduction: Liver transplantation (OLT) for hepatitis B induced liver failure/primary liver cancer comprises 6-10% of all OLT performed in Europe. Prophylaxis against recurrence of the disease remains a controversial issue with several centers using intravenous hepatitis B immune globulin (i.v. HBIG) and oral lamivudine (LAM) which prevents graft reinfection in the majority of patients. It has been recently suggested that prophylaxis based on low doses of intramuscular hepatitis B immune globulin (i.m. HBIG) (400-800 IU) and LAM may be equally effective in prevention of reinfection. This is of importance as prophylaxis with i.v. HBIG is costly and in many countries i.m. preparations of HBIG are significantly less expensive. Aim of the study: To investigate efficacy and tolerability of i.m. HBIG in prevention of the recurrence of hepatitis B after OLT. Material and methods: Four consecutive male Caucasian patients, median age 42 years (range 35-57) who received their OLT for hepatitis B cirrhosis in our centre between 2008 and 2010 were included. During the perioperative period they received an i.v. HBIG/LAM prophylaxis according to our protocol with subsequent ambulatory i.m. HBIG and LAM. The protective level of anti-HBs antibodies was arbitrarily set at 100 mIU/ml. The patients were followed up on 4-8 weeks basis depending on anti-HBs antibody levels. Results: Median follow up was 20 months (range 6-35). Neither of the patients developed reinfection, however the doses required for maintaining a threshold level of anti-HBs antibodies were significantly higher (between 1000 and 2000 IU) than previously recommended. There was a direct correlation between the dose of i.m. HBIG and levels of anti-HBs antibodies. Titration to higher doses allowed longer periods between injections. The treatment was well tolerated. Conclusions: In our experience the prophylaxis against hepatitis B virus (HBV) reinfection with i.m. HBIG and LAM was effective, however, required higher than recommended doses of HBIG. This approach may prove useful in countries where i.m. preparations of HBIG are significantly less costly than i.v. ones.