Editorial LIVER TRANSPLANTATION FOR HEPATITIS B VIRUS END-STAGE LIVER DISEASE: IS IT JUSTIFIABLE?

Although hepatitis B virus (HBV) infection occurs sporadically in Europe and North America, affecting mainly drug abusers and homosexuals, it is endemic in certain areas of the world. HBV is a DNA virus causing silent infection in 90 % of patients and jaundice in the remaining 10 %. Patients presenting with acute hepatitis are at 1 % risk of developing fulminant hepatic failure. Ten percent of patients will develop chronic active hepatitis and have a high risk of developing cirrhosis within 10-30 years and are at higher risk of developing hepatocellular carcinoma1. Liver transplantation is now well accepted as the treatment of choice for a wide variety of end-stage liver diseases2. However, its role in the treatment of patients with HBV related liver cirrhosis remains controversial. This is mainly due to the high morbidity and mortality associated with hepatic graft reinfection and subsequent failure3,4. The first patient with HBV cirrhosis was transplanted in Denver in 1970 and he died 20 months later with disease recurrence5. In 1986, eight patients transplanted for HBV cirrhosis developed reinfection despite receiving perioperative immunoprophylaxis6. Patients with HBV infection are considered immunologically impaired which may explain the high mortality associated with liver transplantation in these patients7. This high morbidity and mortality made many centres consider the presence of HBsAg in the serum as a relative contraindication and the presence of active viral replication, indicated by HBeAg seropositivity, as an absolute contraindication to liver transplantation8. Recent evidence suggests that patients who are HBeAg-negative and HBe antibody-positive may have replicating HBV in their serum and therefore, absence of HBeAg does by no means exclude presence of viral replication9