Canadian Association for the Study of the Liver
Decompensated Hepatitis B cirrhosis
Patients with decompensated HBV-associated liver disease have a poor
prognosis, particularly those with active viral replication. Low-dose interferon
therapy in such patients (HBeAg-positive) may result in one-third responding
with seroconversion and improvement in liver function, but some 20 to 70%
of patients have significant complications from the treatment (40).
Lamivudine appears to yield a better response rate, approaching 80%, without
significant side effects (JP Villeneuve, personal communication).Whether
or not this changes the overall outcome remains to be determined.
Patients with decompensated chronic hepatitis B are candidates for
liver transplantation. Prior to the availability of anti-viral therapy
re-infection of the graft was common. Chronic hepatitis B post-liver transplant
causes aggressive disease and a rapid evolution to cirrhosis and liver
failure.Many liver transplant centres are currently treating these patients
with lamivudine before transplantation.Some patients may improve sufficiently
to avoid or delay the need for transplantation. Timing of the introduction
of lamivudine is important. Waiting times for liver transplantation are
long. Prolonged use of lamivudine pre-transplant may allow the appearance
of the YMDD-variant. These patients develop HBV DNA in serum once more,
and may lose their opportunity for transplantation. Therefore the possibility
of improved liver function must be balanced by the risk of emergence of
viral resistance. Furthermore some patients in transplant studies experience
a return of active hepatitis after developing YMDD-variant HBV; and may
progress to liver failure and death. Loss or partial loss of lamivudine
virologic efficiency in patients with advanced disease and/or immunosuppression
may also be associated with more frequent or more severe disease progression
than is observed in non-decompensated patients. Low dose interferon is
not recommended in decompensated hepatitis B cirrhosis. Patients with decompensated
chronic hepatitis B should be referred to a liver transplant center, and
treatment with lamivudine coordinated with the transplant center.