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上海肝病在线 Shanghai Liver Diseases' Online

从乙肝感染者病人骨髓移植后不同预后重谈----治疗性复合HBV系列疫苗

国外早有文献（参考文献1-27）指出，HBV健康携带者甚至感染过HBV并已自然康复了的白血病人（即抗HBS抗体阳性者，但体内某些地方仍存在复制受抑的HBV病毒，好比/相当于大平年代在监牢的犯人，犯人在监牢服刑而不在社会上犯乱）进行骨髓移植，因采用免疫抑制剂抗排斥反应，致机体免疫功能低下而复制受抑的HBV重新活跃复制并因抗病毒机制不全而激发炎症代偿反应而发为肝炎甚至重症肝炎（如比/相当于监牢的犯人因社会动荡荡不安/乱世而逃出监牢而在社会上胡作非为并成为“乱世英雄”“山大王”）。上述这一现象说明免疫功能（指特异和非特异性抗病毒等免疫功能）与HBV感染发病密切相关。

同样，早年以色列和近年香港又有报道（参考文献28-43），如患有HBV肝炎的病人接受MHC相容性来源并天然感染过HBV并自然康复的供者的骨髓移植的话，该病人所感染的HBV亦同时清除了。但如患有HBV肝炎的病人接受MHC相容性来源并人工接种HBV疫苗（即HBS AG）而只产生抗HBS抗体的供者的骨髓移植的话，该病人所感染的HBV没有清除而仍为HBV感染者并因防止排异反应而免疫抑制剂使用致其发病而为肝炎。上述这一现象则更进一步说明只有产生多位点、多克隆、强力、全方位（细胞免疫和体液免疫即HBV特细胞毒效应和抗HBV的抗体效应）的HBV特异性免疫功能，才能有效清除HBV进而防止肝炎发病。

新近，英国对香港的相关报道研究结果进行更深入的研究（参考文献44），发现只要免疫过继已感染HBV并自然康复的供体HBV核心抗原特异性反应性CD4+（TH1型？？？）便可使患有HBV慢性感染并发为肝炎的骨髓移植受者的HBV清除进而治愈慢性乙肝，HBV核心抗原特异性反应性CD4+和CD8+细胞频率高于HBV表面抗原特异性反应性CD4+和CD8+细胞频率。英国的研究人员据此认为，今后慢性乙肝的治疗性疫苗设计中，其HBV治疗性疫苗组方应考虑HBV核心抗原的基因或抗原蛋白成分。

结合HBV抗原不同免疫靶位点的相互关系研究结合，如HBVS区的前S2和前S1位点对HBS免疫反应的促动效应。以及（上述研究提出的）可能HBC区TH位点对HBV其他抗原免疫反应的促动效应，因此在我们的治疗性复合HBV系列疫苗设计中，我们准备尽可能采用代表HBV各部位抗原的抗原复合肽，并结合不同HBV亚型（国人多adr血清型HBV，但少数民族地区则不一)，采用复合免疫佐剂，以产生明显的多位点、多克隆、强力、HBV特异性全方位（TH1和CTL）效应，充分激活APC/DC免疫感应细胞和TH1和CTL及B细胞等效应细胞，同时提高机体的HBV特异性（清除HBV所必须）和非特异性（防止发病所必须）抗病毒能力，以达到清除HBV并治愈慢乙肝的目的。

参考文献

1]Nordbo SA, Skaug K, Holter E, Waage A, Brinch L. Reactivation of hepatitis B virus infection in an anti-HBc and anti-HBs positive patient after allogeneic bone marrow transplantation. Eur J Haematol 2000 Jul;65(1):86-7

2] Pariente EA, Goudeau A, Dubois F, Degott C, Gluckman E, Devergie A, Brechot C, Schenmetzler C, Bernuau J。Fulminant hepatitis due to reactivation of chronic hepatitis B virus infection after allogeneic bone marrow transplantation.Dig Dis Sci 1988 Sep;33(9):1185-91

A case of hepatitis B reactivation following bone-marrow transplantation for leukemia in a previously healthy HBsAg carrier is reported. A number of changes in HBV serum markers were contemporary to the acute episode. All of them (increase of HBsAg concentration, conversion from anti-HBe to HBeAg, appearance of anti-HBc IgM and of serum HBV-DNA) were suggestive of a "switching-on" of viral replication. Institution of corticosteroid treatment at the onset of the acute phase did not prevent the fatal outcome.

3]Chen PM, Fan S, Liu CJ, Hsieh RK, Liu JH, Chuang MW, Liu RS, Tzeng CH. Changing of hepatitis B virus markers in patients with bone marrow transplantation.Transplantation 1990 Apr;49(4):708-13

The hepatitis B virus (HBV) infection and its resulting hepatic abnormalities are very high in prevalence among the Taiwan population. They also seem to compose a major problem to patients subjected to bone marrow transplantation (BMT) due to intensive chemoradiotherapy. In this study, the sera of 42 patients were investigated before and after BMT to detect the presence of HBV markers and to test their liver function (LF). Being followed-up for 3-12 months after BMT, 12 out of 27 were found to have altered HBV markers according to the classification of the following: seroconversion of HBsAg, clearance of HBsAb, appearance of HBeAg, clearance of HBeAb, and acute hepatitis. Thirty-seven out of 42 patients (88.1%) were found in routine LF test to develop one or more abnormality; however, 90% of them turned normal within one year after BMT. Only one patient died of complications associated with fulminant hepatitis. In conclusion, the previous hepatic damage from HBV infection appears unlikely to increase the risk of posttransplant morbidity and mortality.

4] Fan FS, Tzeng CH, Yeh HM, Chen PM. Reverse seroconversion of hepatitis B virus infectious status after allogeneic bone marrow transplantation from a carrier donor.Bone Marrow Transplant 1992 Aug;10(2):189-91.

A 35-year-old man with acute promyelocytic leukemia received an allogeneic bone marrow transplant (BMT) in second complete remission. The donor was his 18-year-old brother, a chronic hepatitis B virus (HBV) carrier with detectable serum hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg) and hepatitis B virus DNA (HBV DNA). Before BMT, the recipient was immune to HBV, with serum antibody to HBsAg (anti-HBs), antibody to HBeAg (anti-HBe) and normal liver function. Examination of the recipient serum drawn 2 months after BMT revealed reverse seroconversion from anti-HBs/anti-HBe to HBsAg/HBeAg, which remained positive thereafter. Upon reducing cyclosporin 6 months after BMT, acute hepatitis occurred with HBV DNA in serum as evidence of active HBV replication; the patient then developed chronic hepatitis which progressed to cirrhosis and hepatic decompensation within 8 months. Transfusion of HBV DNA/HBeAg-positive bone marrow is thus harmful even when the recipient has anti-HBs prior to BMT.

5]Chen PM, Fan S, Liu JH, Chiou TJ, Hsieh SR, Liu RS, Tzeng CH. Reactivation of hepatitis B virus in two chronic GVHD patients after transplant.Int J Hematol 1993 Oct;58(3):183-8

We report two cases of hepatitis B virus reactivation following allogeneic bone marrow transplantation (BMT) for severe aplastic anemia and acute myelocytic leukemia. The presence of antibodies to HBsAg, HBeAg and HBcAg prior to transplant indicated previous infection with hepatitis B virus (HBV). These antibodies disappeared 2 and 4 months after the onset of chronic graft versus host disease (GVHD) following immunosuppressive treatment, but HBsAg reappeared in their sera 6 and 10 months later, respectively. This suggests that chronic GVHD and immunosuppressive drugs can reactivate HBV in HBsAb-positive patients, most likely because of the decrease in quality and function of helper T cells and B cells during chronic GVHD to induce clearance of HBV antibodies and reactivation of HBV. Our observation confirms that patients with HBsAb, HBeAb and HBcAb present in their sera should not be considered to have 'immunity' to HBV after BMT.

6]Chen YC, Lin KH, Huang WS, Tang JL.Bone marrow transplantation in Taiwan: an overview. Bone Marrow Transplant 1994 Jun;13(6):705-8

In Taiwan, a country with 21 million people, 388 bone marrow transplants (BMTs), 308 allografts and 80 autografts, were performed in 5 BMT centers from November 1983 to October 1993. The commonest indications were leukemia, aplastic anemia, lymphoma and thalassemia. Campaigns promoting an unrelated marrow donor registry were started in August 1993 and recruited approximately 26,000 volunteers. A peripheral stem cell program is just beginning. The overall results of BMT in Taiwan are comparable to other countries. The complications of BMT are similar to Western series, except that acute GVHD was rarer in one large series; this observation needs further study. A particular indication for allogeneic BMT in Taiwan is thalassemia, accounting for 10% of all patients. Disease-free survival after BMT for thalassemia is 44%; graft rejection is the major cause of treatment failure. Another important issue is the role of hepatitis B virus (HBV) in BMT, since the prevalence of HBV infection in Taiwan is very high (> 90%). Abnormal liver function is currently the most common complication and might be related to HBV. Among nearly 100 allogeneic BMTs with HBV carriers as either donor or recipient, 2 patients (approximately 2%) died of HBV-related hepatic failure. Whether the HBV status of the donor and recipient is an important prognostic factor remains to be defined.

7]McIvor C, Morton J, Bryant A, Cooksley WG, Durrant S, Walker N.Fatal reactivation of precore mutant hepatitis B virus associated with fibrosing cholestatic hepatitis after bone marrow transplantation. Ann Intern Med 1994 Aug 15;121(4):274-5

8] Omata F, Ueno F, Kushibiki Y, Takahashi H.Fulminant hepatitis following bone marrow transplantation in hepatitis B virus carrier siblings.J Gastroenterol 1994 Oct;29(5):653-5

A 19-year-old male healthy hepatitis B virus (HBV) carrier developed fulminant hepatitis following allogenic bone marrow transplantation (BMT) from his brother, who was also a healthy HBV carrier, during the first complete remission of acute myelogenic leukemia (M1, FAB classification). Serum markers related to both HBV and hepatitis C virus (HCV) were elevated during active liver injury when a point mutation in the precore (pre-C) region occurred in the HBV. The patient received low-dose interferon alpha (IFN-alpha), while the dose of cyclosporin A was tapered; the patient eventually recovered from the liver injury. Fulminant hepatitis due to HBV and/or HCV following BMT is rare, and it is considered to have a very poor prognosis. The rationale for the use of low-dose IFN-alpha with cyclosporin A (CyA) is discussed.

9] Cooksley WG, McIvor CA. Fibrosing cholestatic hepatitis and HBV after bone marrow transplantation.Biomed Pharmacother 1995;49(3):117-24

Liver failure caused by reactivation of hepatitis B virus (HBV) is an uncommon complication of bone marrow transplantation. Fibrosing cholestatic hepatitis is a recently described liver lesion that develops in some patients undergoing liver transplantation for chronic HBV infection. The lesion is characterised by peri portal fibrosis, ballooning degeneration of hepatocytes, prominent cholestasis and paucity of inflammation. Recent data suggests it is a cytopathic effect of the pre-core mutant form of HBV with over-expression of viral antigens. Although only one case has so far been described associated with bone marrow transplantation (BMT) it is likely that increasing use of BMT in people with chronic HBV infection will lead to further patients being recognised.

10] Huang XJ, Guo NL, Zheng R. [Hepatitis virus infection and bone marrow transplantation] [Article in Chinese]Zhonghua Liu Xing Bing Xue Za Zhi 1995 Apr;16(3):166-70

Hepatitis virus infection is a special problem in China and the role of Hepatitis virus infection in allogeneic bone marrow transplantation (BMT) is not well-defined. In this study, 106 BMT patients were included for analysis of the role of virus infection in allo-BMT. Seven and 65 of 106 patients were found to have HBV infection and HCV infection, respectively. Neither HBV infection and HCV infection interfered with the engraftment of bone marrow cells nor increased the rate of AGVHD, CGVHD, VOID. Neither HBV infection nor HCV infection prohibited allo-BMT. But Hepatitis virus infection can cause mild to moderate liver dysfunction, even death because of acute liver function failure, active prevention and treatment of hepatitis virus infection remains necessary. In this respect, rh-interferon is useful.

11]McIvor C, Morton J, Bryant A, Cooksley WG, Durrant S, Walker N.Fatal reactivation of precore mutant hepatitis B virus associated with fibrosing cholestatic hepatitis after bone marrow transplantation. Ann Intern Med 1994 Aug 15;121(4):274-5

12]Omata F, Ueno F, Kushibiki Y, Takahashi H. Fulminant hepatitis following bone marrow transplantation in hepatitis B virus carrier siblings. J Gastroenterol 1994 Oct;29(5):653-5

13] Cooksley WG, McIvor CA. Fibrosing cholestatic hepatitis and HBV after bone marrow transplantation.Biomed Pharmacother 1995;49(3):117-24

14]Mertens T, Kock J, Hampl W, Schlicht HJ, Tillmann HL, Oldhafer KJ, Manns MP, Arnold R.Reactivated fulminant hepatitis B virus replication after bone marrow transplantation: clinical course and possible treatment with ganciclovir.Hepatol 1996 Dec;25(6):968-71

A female chronic hepatitis B virus carrier (HBV-DNA negative) suffered from simultaneous hepatitis B virus and cytomegalovirus reactivation after in vivo T cell depletion preceding transplantation of an in vitro T cell depleted marrow graft for treatment of acute leukaemia. Interstitial pneumonia developing after bone marrow transplantation was successfully treated with ganciclovir (day 13 until day 46). The initially unnoticed extensive hepatitis B virus replication finally led to clinical hepatitis (day 85) and liver failure (day 96). Liver transplantation was performed, but the patient died from septicaemia. Retrospective analysis of hepatitis B virus DNA revealed that the HBV replication started immediately after T cell depletion and was completely suppressed during ganciclovir administration. Screening for HBV-DNA seems to be mandatory in comparable cases, and antiviral chemotherapy should be seriously considered.

15] Ustun C, Koc H, Karayalcin S, Akyol G, Gurman G, Ilhan O, Akan H, Ozcan M, Arslan O, Konuk N, Uysal A, Beksac M. Hepatitis B virus infection in allogeneic bone marrow transplantation. Bone Marrow Transplant 1997 Aug;20(4):289-96

Fourty-four patients who underwent allogeneic bone marrow transplantation (alloBMT) were studied for hepatitis B virus (HBV)-related complications. The mean follow-up period was 15.3 months. Positivity for HBV surface antigen (HBsAg) was observed in 10 patients (22.7%) throughout the study. Four of the 10 patients were HBsAg carriers before alloBMT, while the remaining six became HBsAg(+) after alloBMT. During the follow-up period (from 6 months to 45 months), an elevation in serum ALT activity was observed in the four carriers when immunosuppression was reduced or withdrawn. All of the four HBsAg carriers developed hepatitis, but none of them died of liver failure due to HBV. Only one death due to GVHD and diabetic ketoacidosis was observed in this group. Two of the four carriers received marrow from anti-HBs positive donors and one of them cleared HBsAg from his serum via adoptive immunity 8 months after transplantation. The remaining six patients acquired HBV after alloBMT, but we were unable to demonstrate the source of HBV. Five of them had a moderate increase in serum ALT activity while the other patient had a normal ALT. Two patients seroconverted to anti-HBs spontaneously. Two patients died during the follow-up, one due to intracranial hemorrhage and the other due to GVHD and accompanying pulmonary infection. The rest of the study group (34 patients) remained HBsAg(-) throughout the study. Two of them had an HBsAg(+) donor, but neither developed HBV infection in their follow-up period. The acquisition rate of HBV infection was relatively low in recipients who were positive for anti-HBs compared to those who were negative for anti-HBs (8 vs 19%). Anti-HBs positivity remained for a longer period in recipients who received marrow from anti-HBs positive donors compared to those recipients who had anti-HBs negative donors (median 12 vs 3 months). We think that HBV is a frequent cause of liver dysfunction in alloBMT patients where HBV infection is endemic. Whether the disease is in the form of reactivation of HBsAg-positive recipients, or is acquired from unknown sources in recipients who never had contact with the virus, the course of the disease is not fatal. Silent serologic changes can be demonstrated if viral serologic markers are sought serially. Among them, the disappearance of serum anti-HBs may be important as it increases the risk of HBV contamination in recipients.

16] Caselitz M, Link H, Hein R, Maschek H, Boker K, Poliwoda H, Manns MP.Hepatitis B associated liver failure following bone marrow transplantation.J Hepatol 1997 Sep;27(3):572-7

BACKGROUND: Several cases have been reported showing clearance of HBsAg in chronic hepatitis B carriers due to adoptive transfer of immunity by an hepatitis B immunised bone marrow. CASE REPORT: We report on a 27-year-old man with chronic myelocytic leukemia and asymptomatic chronic hepatitis B who received allogeneic bone marrow transplantation (BMT). The donor was his HLA identical brother with natural immunity against hepatitis B. Before BMT the donor had received an additional dose of recombinant hepatitis B vaccine. Twenty days after BMT alanine aminotransferase levels increased and graft versus host disease of the skin was observed. Elevation of liver enzymes was initially attributed to graft versus host disease of the liver and the patient received high doses of steroids in addition to standard immunosuppression. Alanine aminotransferase levels increased up to a maximum on day 52 while the HBV DNA level peaked on day 38 after BMT. A liver biopsy showed reactivation of hepatitis B and treatment with steroids was tapered down. Although alanine aminotransferase and HBV DNA levels decreased, liver function deteriorated. The patient died 130 days after BMT due to liver failure. CONCLUSION: This report indicates that disturbance of the balance between HBV replication and immune control after BMT may result in fatal reactivation of hepatitis B. Careful monitoring, including HBV DNA level and early liver biopsy, of patients with chronic hepatitis B undergoing BMT as well as determination of the HBV immune status of the BMT donor is suggested and necessary.

17] Locasciulli A, Testa M, Valsecchi MG, Vecchi L, Longoni D, Sparano P, Rovelli A, Uderzo C, Masera G, Alberti A.Morbidity andmortality due to liver disease in children undergoing allogeneic bone marrow transplantation: a 10-year prospective study. Blood 1997 Nov 1;90(9):3799-805

We have conducted a long-term prospective study of children undergoing bone marrow transplantation (BMT) to assess morbidity and mortality for liver disease. One hundred eleven consecutive children were enrolled between June 1985 and June 1995 and were followed-up for a median of 5.5 years after BMT. Before transplant 48/111 children (43%) had abnormal alanine aminotransferase (ALT), none were HBsAg+ and 4/111 were anti-HCV+. After BMT 4/111 patients (3. 6%) died of liver failure. No relationship was found between pretransplant hepatitis B (HBV) or C (HCV) infection or elevated transaminases and development of severe liver damage. Eighty-two out of one hundred and eleven patients (74%) had abnormalities of ALT after BMT, transient (n = 54) or persistent (n = 28). None developed clinical signs or symptoms of end stage liver disease or of cirrhosis during follow-up. No significant difference in prevalence of liver disease, was found between children with normal or abnormal ALT at BMT (relative risk [RR] = 1.04). HCV infection could be implicated in the etiology of chronic liver disease in 14/28 patients; 2 other patients were found infected by HBV alone (1 case) or combined with HCV (1 case). In the remaining 12 the etiology of chronic liver disease could not be defined. Posttransplant hepatitis B occurred in 4/111 children (3.6%), including a recipient from a donor who had been previously vaccinated against HBV, while no patient who had been vaccinated developed hepatitis B. The rate of posttransplant seroconversion to anti-HCV was 15%. PMID: 9345068 [PubMed - indexed for MEDLINE]

18]Li Volti S, Pizzarelli G, Galimberti M, Di Gregorio F, Romeo MA, Lucarelli G, Russo G.Clinical and biochemical reactivation of HBV infection in a thalassemic patient after bone marrow transplantation. Infection 1998 Jan-Feb;26(1):58-60

The case of a young man affected by homozygous beta-thalassemia is reported who had serologic findings of a prior HBV infection and who presented with clinical and biochemical acute HBV infection probably caused by HBV reactivation after allogeneic bone marrow transplantation. The patient's clinical history suggests that HBV can persist without serological findings of HBsAg and HBV-DNA in persons previously infected by HBV and that HBV reactivation can occur 2 years after allogeneic bone marrow transplantation, as a result of immunosuppressive therapy or an HCV activation.

19]Dhedin N, Douvin C, Kuentz M, Saint Marc MF, Reman O, Rieux C, Bernaudin F, Norol F, Cordonnier C, Bobin D, Metreau JM, Vernant JP.Reverse seroconversion of hepatitis B after allogeneic bone marrow transplantation: a retrospective study of 37 patients with pretransplant anti-HBs and anti-HBc.Transplantation 1998 Sep 15;66(5):616-9

BACKGROUND: Reverse seroconversion to hepatitis B virus (HBV), i.e., HBV reactivation in patients with pretransplant antibodies to hepatitis B surface antigen (anti-HBs) and to hepatitis B core antigen (anti-HBc), is rarely re-ported after allogeneic bone marrow transplantation. METHODS: To determine this risk, we studied clinical outcome and serological changes in 37 patients with pretransplant anti-HBs and anti-HBc. RESULTS: In 33 cases, no change in HBV markers was observed in the posttransplant period. In four cases, anti-HBs and anti-HBc were lost, and hepatitis B surface antigen, hepatitis B e antigen, and HBV DNA emerged together with acute hepatitis, after cessation of immunosuppression. The actuarial risk of reactivation in the 37 patients was 20.5% (median follow-up 20 months). No reactivation occurred in patients with anti-HBs-positive donors. CONCLUSION: Although few cases of postallogeneic bone marrow transplantation reverse seroconversion to HBV have been reported, this study demonstrates that the actuarial risk is relatively high and suggests that donor vaccination might be proposed prophylactically or that HBs-specific immunoglobulin infusions might be warranted.

20] Blanpain C, Knoop C, Delforge ML, Antoine M, Peny MO, Liesnard C, Vereerstraeten P, Cogan E, Adler M, Abramowicz D. Reactivation of hepatitis B after transplantation in patients with pre-existing anti-hepatitis B surface antigen antibodies: report on three cases and review of the literature. Transplantation 1998 Oct 15;66(7):883-6

BACKGROUND: Patients who have been exposed to the hepatitis B virus (HBV) and who were able to clear the hepatitis B surface antigen from the serum and to develop anti-hepatitis B surface antigen (anti-HBs) antibodies are not considered at risk for HBV reactivation after solid organ transplantation. METHODS AND RESULTS: We, however, observed three solid organ transplant recipients who demonstrated clinically significant HBV reactivation after transplantation. All patients presented normal liver enzymes and serological stigmates of healed HBV infection at the time of transplantation, as indicated by the absence of hepatitis B surface antigen and the presence of anti-HBs and anti-hepatitis B core antibodies in the serum. Patient 1, a renal transplant recipient, presented HBV reactivation 3 years after transplantation and developed chronic HBV hepatitis. Patient 2 developed HBV reactivation 7 months after a second cadaveric renal graft and died of cirrhosis four and a half years after transplantation. Patient 3, a heart-lung transplant recipient, developed HBV reactivation within months after transplantation, but died of unrelated causes. HBV reactivation in the presence of anti-HBs antibodies has been previously reported in other settings of immunosuppression, mainly in patients with acquired immunodeficiency syndrome and after bone marrow transplantation, and may lead to fatal liver disease. Data from our renal transplant recipients suggest that the incidence of HBV reactivation among patients with anti-HBs and anti-hepatitis B core antibodies is about 5%. CONCLUSIONS: Transplant physicians should be aware of the risk of HBV reactivation in patients presenting with healed HBV infection before transplantation.

21]Chen PM, Chiou TJ, Fan FS, Liu JM, Hsieh RK, Yen CC, Wang WS, Liu JH. Fulminant hepatitis is significantly increased in hepatitis B carriers after allogeneic bone marrow transplantation. Transplantation 1999 Jun 15;67(11):1425-33

BACKGROUND: Bone marrow transplantation (BMT) is effective treatment for many hematologic disease, but performed in a population with a high endemic hepatitis B virus carrier rate, the incidence of liver function impairment and fulminant hepatitis (FH) is expected to be raised. METHODS: Forty-three hepatitis B virus carriers received high-dose chemotherapy and BMT, 32 patients received an allogeneic graft, and 11 patients autologous marrow. Acute graft-versus-host disease prophylaxis consisted of methotrexate on day 1, 3, 6, and 11 and cyclosporine for 6 months. RESULTS: After a median follow-up period of 68 months (range: 1-11.5 years), 26 (81.3%) allogeneic BMT patients developed impaired liver function (LF), 5 progressed to FH on day 93, 169, 170, 180, and 468, respectively, and died after an average of 13.8 days (range: 1-45 days). Whereas only 4 (36.4%) autologous BMT patients developed impaired LF, and none FH. Impaired LF (P=0.026, chi-square), and FH (odds ratio=12.86, P=0.009 for coefficient) were significantly related to an allogeneic marrow graft, and the timing of liver function impairment coincided with cyclosporine withdrawal. Hepatitis B surface antigen (HbsAg) disappeared from the serum in 4/14 (28.6%) patients receiving a marrow graft from an HbsAg+ donor. HbsAg was not detected in the serum after BMT in 2/11 (18.2%) autologous BMT patients. CONCLUSIONS: Hepatitis B virus carriers receiving a marrow graft from an HbsAg+ donor have a significantly increased risk of FH.

22]Romand F, Michallet M, Pichoud C, Trepo C, Zoulim F. [Hepatitis B virus reactivation after allogeneic bone marrow transplantation in a patient previously cured of hepatitis B] [Article in French] Gastroenterol Clin Biol 1999 Jun-Jul;23(6-7):770-4

The presence of antibodies to HBs and HBc antigens indicates previous infection with hepatitis B virus but does not necessarily reflect viral clearance. Immunosuppression such as that observed in patients with bone marrow transplantation may be responsible for viral reactivation followed by acute exacerbation after withdrawal of immunosuppressive therapy. We report a case in a patient with natural immunity to hepatitis B who had undergone allogenic bone marrow transplantation with an identical sibling donor one year before for the chronic myelogenous leukemia in the first chronic phase. Ganciclovir treatment resulted in control of hepatitis virus B replication and in biochemical remission. We suggest that prevention relies on serological evaluation and therapy with active or passive immunisation or antiviral drugs in case of a rapid decline of anti-HBs Ab titers to undetectable levels.

23] Locasciulli A, Testa M, Valsecchi MG, Bacigalupo A, Solinas S, Tomas JF, Ljungman P, Alberti A.The role of hepatitis C and B virus infections as risk factors for severe liver complications following allogeneic BMT: a prospective study by the Infectious Disease Working Party of the European Blood and Marrow Transplantation Group. Transplantation 1999 Nov 27;68(10):1486-91

BACKGROUND: Severe liver disease, including fulminant hepatic failure and venoocclusive disease can occur after bone marrow transplantation (BMT). The aim of our study was to assess risk factors for veno occlusive disease and severe liver disease occurring within 6 months from BMT. METHODS: A total of 193 consecutive patients from 15 BMT Centers were prospectively enrolled between January and June 1995. Data on donors and recipients before and after transplant were collected and included age, gender, alanine aminotransferase (ALT), hepatitis B (HBV), and hepatitis C virus (HCV) markers, hematological disease, status and type of BMT, conditioning regimen and graft versus host disease prophylaxis. Statistical analysis included univariate descriptive and multivariate analysis based on logistic regression on major end-points. RESULTS: Forty-three of 193 patients died during the study period, and liver disease was the main cause of death (13 of 43, 30%). Incidence of severe veno occlusive disease was 8%, fulminant hepatic failure 0.5% and 12% of cases had ALT >500 U/L (normal < or =42 U/L). A de novo HBV or HCV infection occurred in 3.2 and 7% of patients respectively. Predictive risk factors for life-threatening liver disease were: unrelated donors (relative risk=5.8, confidence interval=1.7-19.8) and abnormal BMT donor ALT (relative risk=6.3, confidence interval=1. 5- 25.5). CONCLUSIONS: This study indicates that ongoing or previous infection with HBV or HCV in donor or recipient is not an absolute contraindication for BMT. However, abnormal ALT levels in BMT donors were a significant predictor of potentially lethal liver complications. The occurrence of de novo HBV or HCV infection did not correlate with severity of liver disease observed in the first 6 months posttransplant. These findings should be carefully evaluated before disregarding HBV or HCV positive siblings with normal transaminase levels in favor of unrelated donors.

24] Iwai K, Tashima M, Itoh M, Okazaki T, Yamamoto K, Ohno H, Marusawa H, Ueda Y, Nakamura T, Chiba T, Uchiyama T. Fulminant hepatitis B following bone marrow transplantation in an HBsAg-negative, HBsAb-positive recipient; reactivation of dormant virus during the immunosuppressive period. Bone Marrow Transplant 2000 Jan;25(1):105-8

It is widely accepted that seroconversion of HBsAg to HBsAb indicates clearance of hepatitis B virus. We describe a 50-year-old man with chronic myelocytic leukemia who developed lethal hepatitis B 22 months after allo-BMT. He had been negative for HBsAg and positive for HBsAb before BMT. Hepatitis B virus latently existing in the liver cells before BMT proliferated during the immunosuppressed period causing fatal hepatitis. Recipients with positive HBsAb should be considered to have the potential for active hepatitis B to emerge after BMT.

25]Endo T, Sawada K, Fujimoto K, Yamamoto S, Takashima H, Haseyama Y, Nishio M, Koizumi K, Koike T. [Reactivation of hepatitis B virus after autologous peripheral blood stem cell transplantation in patients with positive hepatitis B surface antibodies] [Article in Japanese] Rinsho Ketsueki 2000 Apr;41(4):322-8

Hepatitis B virus (HBV) reactivation in patients with positive hepatitis B surface antibody (HBsAb) has been reported in some cases of allogenic bone marrow transplantation, acquired immunodeficiency syndrome (AIDS), and organ transplantation. However, to our knowledge, no reports have been made on the frequency and risk factors involved in HBV reactivation after autologous peripheral blood stem cell transplantation (APBSCT). Forty seven patients who underwent APBSCT were retrospectively analyzed. Three patients who were HBsAb positive before APBSCT contracted post-transplant HBV acute hepatitis. All 3 patients had multiple myeloma. HBV DNA could not be demonstrated in preserved samples of transfused blood. Therefore, we speculated that reactivation of latent HBV had occurred. The 3 patients with HBV hepatitis had relatively lower titers of pre-transplant HBsAb, and the total dose of steroids they received after APBSCT was significantly higher than for other patients who did not experience post-transplant HBV reactivation. There were no significant differences in pre-transplant hepatitis B core antibody (HBcAb) titer or total post-transplant blood transfusion volume. Our study suggested that immunocompromised states, especially those induced by high-dose steroid therapy, may allow the reactivation of HBV after APBSCT, even in patients who had HBsAb before APBSCT.

26] Nordbo SA, Skaug K, Holter E, Waage A, Brinch L. Reactivation of hepatitis B virus infection in an anti-HBc and anti-HBs positive patient after allogeneic bone marrow transplantation.Eur J Haematol 2000 Jul;65(1):86-7

27]Hashino S, Nozawa A, Izumiyama K, Yonezumi M, Chiba K, Kondo T, Suzuki S, Hige S, Asaka M. Lamivudine treatment for reverse seroconversion of hepatitis B 4 years after allogeneic bone marrow transplantation. Bone Marrow Transplant 2002 Feb;29(4):361-3

Reverse seroconversion of hepatitis B virus (HBV) after allogeneic BMT is rare. We present a case of HBV reactivation late after allogeneic BMT which responded well to lamivudine therapy. A 35-year-old woman with CML received an allogeneic BMT. Before BMT, the patient had immunity to HBV, with serum antibodies against hepatitis B surface antigen (HBsAb), and the donor was completely negative for HBV. Four years after BMT, acute hepatitis occurred with a detectable level of HBV-DNA. Lamivudine rapidly reduced transaminase and bilirubin levels, and serum HBV-DNA decreased to negative. Retrospective analysis revealed that there had been a gradual decrease in serum HBsAb titers after BMT. Administration of lamivudine immediately after HBV replication may be more effective than vaccination of hepatitis B surface antigen-negative donors before BMT.

28]Ireland J, Hino K, Lau GK, Cheng CC, Carman WF. Failed adoptive immunity transfer: reactivation or reinfection? J Viral Hepat 1999 Jan;6(1):73-8

A 26-year-old female bone marrow transplant (BMT) recipient was hepatitis B surface antigen (HBsAg) and hepatitis B e antibody (HBeAb) positive. The donor, her human leucocyte antigen (HLA)-compatible sister, was HBsAg negative but hepatitis B surface antibody (HBsAb) and hepatitis B core antibody (HBcAb) positive. Twelve weeks post-BMT the patient became HBsAg negative, as determined using a monoclonal antibody-based assay. At 16 weeks post-BMT, HBsAg became undetectable by monoclonal and polyclonal immunoassay with seroconversion to HBsAb; however, at 24 weeks post-BMT the patient again became HBsAg positive. Both the recipient and the donor were retrospectively tested by hepatitis B virus (HBV) polymerase chain reaction (PCR) and found to be positive. The recipient displayed variants at amino acids 4 and 47 of the surface (S) gene prior to BMT. These mutations were not detected 32 weeks post-BMT when the S gene sequence was identical to that of an adr prototype. The donor was found to have four unique amino acid substitutions at positions 30, 98, 101 and 210 of the S gene. However, in vitro-expressed HBsAg from the donor was detected by commercial kits and an immunofluorescence assay, indicating that antigenic alteration did not explain HBsAg negativity. This donor highlights the value of PCR as the gold standard test for current HBV infection. It also demonstrates that discordance between two commercial HBsAg assays may not always be caused by antigenic variants. The second episode of hepatitis may theoretically have been caused by reactivation, selection of an escape mutant by HBsAb, reinfection or recombination. We suggest it was reactivation because none of the donor variants was seen in the recipient post-BMT.

29]Liang R, Lau GK, Kwong YL.Chemotherapy and bone marrow transplantation for cancer patients who are also chronic hepatitis B carriers: a review of the problem.J Clin Oncol 1999 Jan;17(1):394-8

In places where hepatitis B virus (HBV) infection is endemic, it is often necessary to give chemotherapy to or perform bone marrow transplantation for cancer patients who are also chronic HBV carriers. When standard chemotherapy was given to lymphoma patients, elevation of liver transaminases was observed in nearly half of those who were chronic HBV carriers. Ten percent of them became jaundiced, and the overall liver-related mortality was about 5%. There is currently no reliable way to predict the severity of HBV reactivation after chemotherapy. The risk is probably higher when the chemotherapy used is significantly immunosuppressive and the viral load in the liver is high. Different strategies have been used in an attempt to reduce the risk of HBV reactivation after chemotherapy, but they have not been very successful. Further studies will be required to determine the impact of newly available antiviral agents that are active against HBV. Recipients who are carriers of HBV or who receive hepatitis B surface antigen (HBsAg)-positive marrow are at increased risk of hepatitis B-related morbidity and mortality after bone marrow transplantation (BMT). There is evidence to suggest that prophylactic use of an active antiviral agent, such as famciclovir, may result in a significant decrease in the incidence and severity of HBV reactivation after BMT. Sustained serologic clearance of chronic HBV infection has also been reported in many HBsAg-positive marrow recipients receiving hepatitis B surface antibody-positive marrow from their allogeneic donors. There seems to be a transfer of both humoral and cellular immunity against HBV from donors to recipients. Further prospective studies are required to define the best approach to manage HBsAg-positive cancer patients receiving chemotherapy or BMT. It is recommended that all cancer patients be checked for their hepatitis B status before receiving chemotherapy or a bone marrow transplant, especially if they reside in or come from endemic areas of HBV infection.

30] Locasciulli A, Alberti A, Bandini G, Polchi P, Arcese W, Alessandrino P, Bosi A, Testa M, Bacigalupo A. Allogeneic bone marrow transplantation from HBsAg+ donors: a multicenter study from the Gruppo Italiano Trapianto di Midollo Osseo (GITMO).Blood 1995 Oct 15;86(8):3236-40

Hepatitis B virus (HBV)-infected individuals are occasionally used as donors for bone marrow transplantation (BMT). We studied the rate of HBV infection and the clinical expression of the associated liver disease in patients receiving marrow from HBsAg+ donors. We performed a retrospective survey in 14 BMT units in Italy in which all BMTs performed between 1984 and 1994 were reviewed and those involving HBsAg+ donors were identified. Donors and recipients were analyzed for HBV markers and liver disease. A total of 24 of 2,586 patients (0.9%) had received an HBsAg+ marrow. HBsAg became detectable in 22% of pre-BMT HBsAg- patients, but only 5.5% became chronic HBsAg carriers. Antigenemia developed more frequently in anti-HBs- compared with anti-HBs+ patients independently of passive prophylaxis with hyperimmune anti-HBs Ig, although the difference was not significant. Severe liver failure with death occurred in 21% of patients, which was a value greater than that generally observed after BMT in our units (3.7%). Patients with an anti-HBe+ donor had higher frequency of liver failure (28% v 0%) and alanine aminotransferase peaks as compared with those of patients with an HBeAg+ donor. Liver failure was not observed in anti-HBs+ recipients. The use of HBsAg+ donors, particularly if anti-HBe+, increases the risk of severe liver disease in BMT recipients. Anti-HBs positivity may prevent severe liver damage.

31]Ilan Y, Nagler A, Adler R, Tur-Kaspa R, Slavin S, Shouval D.Ablation of persistent hepatitis B by bone marrow transplantation from a hepatitis B-immune donor.Gastroenterology 1993 Jun;104(6):1818-21

Chronic hepatitis B virus (HBV) infection is still a major cause of liver disease for which no definite therapy is available. We describe here a hepatitis B surface antigen (HBsAg) carrier patient with active viral replication (HBV DNA positive) who was treated for leukemia by bone marrow transplantation (BMT) from an HBV immune donor. Following BMT from the antibody to hepatitis B core antigen (anti-HBc) positive/anti-HBs positive bone marrow donor, immune reconstitution of the recipient's bone marrow resulted in clearance of the circulating HBsAg, as well as HBV DNA. The patient acquired immunity against HBV, which lasted for more than 8 months posttransplantation. Therefore, this report provides evidence that adoptive transfer of specific immunity against HBV through allogeneic BMT may lead to clearance of persistent HBV infection. Furthermore, the data support the hypothesis that the HBsAg carrier state is most probably the result of an inefficient immune response against HBV, implying that clearance of HBV may be facilitated by adoptive cellular immunotherapy.

32]Shouval D, Adler R, Ilan Y. Adoptive transfer of immunity to hepatitis B virus in mice by bone marrow transplantation from immune donors.Hepatology 1993 Jun;17(6):955-9

Recipients of allogeneic bone marrow transplantation are immunosuppressed as a result of their primary disease and by myeloablative therapy. Such patients are dependent on multiple blood products and are at risk for hepatitis B virus infection. Active immunization against hepatitis B in the immediate pre- and post-transplant periods is ineffective, presumably because of decreased T cell-dependent B-cell responses. This study was designed to evaluate, in a mouse model system, the transfer of immunity against hepatitis B to bone marrow transplant recipients through immunization of bone marrow donors against hepatitis B before transplantation. Bone marrow donor BALB/c mice were immunized with a recombinant hepatitis B vaccine. Seroconversion to HBs antibody occurred within 4 wk of primary immunization, and antibody levels in treated donor mice rose above 300 mIU/ml after a single booster injection. Bone marrow recipient mice, conditioned by sublethal irradiation, were injected intravenously with bone marrow cells obtained from syngeneic HBs antibody-positive immune donors. Antibody was detected in 10% of bone marrow recipients within 30 days of transplantation and in 56% 1 mo after a booster injection that led to a secondary rise in HBs antibody. Adoptive transfer of immunity to hepatitis B also occurred after transplantation of T cell-depleted bone marrow cells from hepatitis B-immune donors, albeit at a lower HBs antibody level. These results indicate that immunity to hepatitis B can be transferred in mice by bone marrow transplantation from hepatitis B-immune donors to immunosuppressed recipients.(ABSTRACT TRUNCATED AT 250 WORDS)

33]Ilan Y, Nagler A, Adler R, Naparstek E, Or R, Slavin S, Brautbar C, Shouval D. Adoptive transfer of immunity to hepatitis B virus after T cell-depleted allogeneic bone marrow transplantation. Hepatology 1993 Aug;18(2):246-52

Recipients of allogeneic bone marrow transplantation are pancytopenic for several weeks and immunosuppressed for many months as a result of myeloablative therapy required to eliminate the basic disease and to prevent allograft rejection. After bone marrow transplantation, these patients remain profoundly immunosuppressed by the chemotherapy and immunotherapy used as prophylaxis against graft-vs.-host disease, treatment of established disease or both. These patients are usually dependent on multiple blood products and are therefore at risk for hepatitis B virus infection, which may run a fulminant course. Active immunization against hepatitis B virus in the immediate pre-bone marrow transplantation and post-bone marrow transplantation periods was found to be ineffective, probably because of the absence of T cell-dependent B-cell responses, which persists for approximately 1 yr after bone marrow transplantation. We studied adoptive transfer of immunity to hepatitis B virus through bone marrow transplantation in two populations of patients. The first group (A) consisted of 12 pairs of BMT donors and recipients, in which all bone marrow donors were positive for antibodies to HBc and HBs as a result of previously acquired hepatitis B virus infection and resolution; all recipients were negative to antibodies to HBc and HBs. The second group (B) consisted of eight pairs of donors and recipients in which all the donors were actively immunized against hepatitis B virus before bone marrow transplantation; all recipients were negative for all hepatitis B virus markers. All bone marrow transplantation recipients were monitored for antibodies to hepatitis B virus antigens.(ABSTRACT TRUNCATED AT 250 WORDS)

34] Ilan Y, Nagler A, Shouval D, Ackerstein A, Or R, Kapelushnik J, Adler R, Slavin S. Development of antibodies to hepatitis B virus surface antigen in bone marrow transplant recipient following treatment with peripheral blood lymphocytes from immunized donors.Clin Exp Immunol 1994 Aug;97(2):299-302

Bone marrow transplantation (BMT) recipients are immunosuppressed and are at risk for contracting severe infections. Recently, adoptive transfer of immunity against hepatitis B virus (HBV) was documented in BMT recipients receiving bone marrow from 'naturally' HBV-infected individuals who recovered spontaneously, or those transplanted with bone marrow cells obtained from actively immunized donors. Furthermore, reconstitution of the immune system in a BMT recipient who was a hepatitis surface antigen (HBsAg)+/HBV DNA+ carrier with HBV immune bone marrow cells led to clearance of the replicating virus, presumably through adoptive cell-mediated immunotherapy. We report three cases of induction of immunity to HBV by selective adoptive transfer by i.v. injection of peripheral blood lymphocytes (PBL) obtained from BMT donors who were actively immunized against HBV after harvesting of bone marrow. All three BMT recipients developed anti-HBs antibodies. In one BMT case in whom antibodies to HBsAg developed following adoptive transfer of immune PBL, a mild booster effect was documented in the BMT recipient upon immunization with a recombinant hepatitis B vaccine. The two remaining patients lost their antibodies to HBsAg in association with relapse of leukaemia. This immune manipulation may open the door to evaluation of adoptive transfer of immunity to HBV through selective transplantation of HBV immune lymphocytes in selected patients such as those with persistent HBV infection, as well as liver transplant recipients who require protection of the graft against HBV re-infection.

35]Shouval D, Ilan Y.Immunization against hepatitis B through adoptive transfer of immunity. Intervirology 1995;38(1-2):41-6

Clearance of hepatitis B virus (HBV) infection requires an effective T-cell-dependent humoral response that is often defective in HBV carriers and in immunosuppressed patients. We have shown in mice and humans that bone marrow (BM)-derived memory cells, capable of producing antibodies to the HBV envelope and nucleocapsid antigens, are transferable from BM donors (BMD) to their recipients. BMD BALB/c mice were immunized with recombinant HBV surface antigen (HBsAg), and BM from anti-HBs-positive donors was transplanted to irradiated recipient mice, who seroconverted to anti-HBs within 30 days of bone marrow transplantation (BMT), and responded to booster vaccination. In a similar manner, 19/26 human BM recipients, who received their HLA-matched BM from BMDs immunized once with HBsAg, seroconverted within several weeks after BMT. Antibodies to HBsAg were also observed in 3 recipients of peripheral blood lymphocytes (PBL) obtained from HLA-matched immunized human donors. Finally, clearance of HBsAg and HBV DNA was observed in an HBsAg carrier with leukemia who received BMT from his HLA-matched anti-HBc+/anti-HBs+ brother. These results indicate that adoptive transfer of immunity to HBV may be achieved through immunization of BM or PBL donors against HBV.

36]Nagler A, Ilan Y, Adler R, Or R, Naparstek E, Shouval D, Slavin S. Successful immunization of autologous bone marrow transplantation recipients against hepatitis B virus by active vaccination.Bone Marrow Transplant 1995 Mar;15(3):475-8

Patients undergoing autologous bone marrow transplantation (BMT) are severely immunosuppressed. These patients are exposed to various infections agents due to delayed and efficient reconstitution of their immune system. Forty-eight patients with hemato-oncological malignancies were immunized against hepatitis B virus (HBV) following autologous BMT. Twenty one were vaccinated more than 10 days before BMT, 17 on days 1-9 before and 10 day after BMT. Thirty three patients (68.7%) seroconverted within 40 days after autologous BMT after receiving one dose of the vaccine before autologous BMT with a relatively low level of anti-HBs, whereas in 11 no anti-HBV antibodies could be detected. Nineteen patients remained seropositive but in 11 the seroconversion was only transient no correlation was found between permanent or transient seroconversion and basic disease, conditioning regimens, post-transplant therapy, immunotherapy and day of vaccination in relation to autologous and day of vaccination in relation to autologous BMT. Active HBV immunization of patients with malignancy undergoing autologous BMT is feasible and levels of antibodies, although low, are above the conventional protective titers. Therefore active immunization of some patients may reduce hepatitis-related complications in the setting of autologous BMT.

37]Shouval D, Ilan Y.Transplantation of hepatitis B immune lymphocytes as means for adoptive transfer of immunity to hepatitis B virus. J Hepatol 1995 Jul;23(1):98-101

38]Nagler A, Ilan Y, Varadi G, Kapelushnik J, Or R. In vivo CAMPATH-1 followed by T cell-depleted bone marrow transplantation: a potential new mode of therapy for hepatitis-associated severe aplastic anemia (SAA). Bone Marrow Transplant 1996 Aug;18(2):475-8

Bone marrow transplantation (BMT) has been previously reported as a successful mode of treatment for hepatitis B and associated severe aplastic anemia (SAA). Non-A, non-B, non-C hepatitis is one of the causes of SAA. The etiology of SAA caused by non-A, non-B, non-C hepatitis is unknown. There is evidence that the immune response and, specifically, T cells and monocytes have a major role in both HCV- and HBV-induced liver damage. The liver damage caused by non-A, non-B, non-C hepatitis may be associated with similar mechanisms. We describe an 8-year-old girl who developed SAA post-non-A, non-B, non-C hepatitis infection. She was treated by in vivo CAMPATH-1G antibodies followed by T cell depleted HLA-matched BMT and cyclosporin A, resulting in gradual improvement and almost normalization of liver function. We suggest that treatment with CAMPATH-1G followed by T cell-depleted BMT and cyclosporin A could be a novel mode of therapy for viral non-A, non-B, non-C hepatitis-induced liver damage and associated SAA.

39] Lau GK, Lok AS, Liang RH, Lai CL, Chiu EK, Lau YL, Lam SK.Clearance of hepatitis B surface antigen after bone marrow transplantation: role of adoptive immunity transfer. Hepatology 1997 Jun;25(6):1497-501

Adoptive immunity transfer has been reported to be effective in clearing chronic hepatitis B virus (HBV) infection. Two hundred twenty-six patients who received allogeneic bone marrow transplantation (BMT) between May 1990 and September 1995 were screened for hepatitis B markers. Twenty-one patients were hepatitis B surface antigen (HBsAg) positive before BMT. The median follow-up period was 20 months (range, 2-59 months). Two of these patients had sustained clearance of HBV infection after transplantation. Both patients were hepatitis B e antigen (HBeAg)-negative, hepatitis B e antibody (anti-HBe)-positive, and serum HBV DNA-negative (by dot-blot hybridization) before BMT. Both had a flare in the serum alanine transaminase (ALT) level around the time of HBsAg clearance. Sustained clearance of HBsAg was observed in 2 of the 5 patients who received hepatitis B surface antibody (anti-HBs)-positive marrow but in none of the 16 patients who received anti-HBs-negative marrow (P < .05). One additional patient who received anti-HBs-positive marrow had transient HBsAg seroconversion. Among the 18 patients who remained persistently HBsAg-positive after BMT, 3 had HBeAg seroconversion and 3 had reversion to HBeAg positivity. In this study, we found a significant association between clearance of HBV infection and anti-HBs-positive bone marrow donors. Adoptive immunity transfer is effective in clearing HBV from patients with chronic HBV infection.

40]Ilan Y, Gabay E, Amit G, Feder R, Galun E, Adler R, Shouval D. Suppression of human hepatoma in mice through adoptive transfer of immunity to the hepatitis B surface antigen. J Hepatol 1997 Jul;27(1):170-5

BACKGROUND/AIMS: Adoptive transfer of immunity against hepatitis B surface antigen (HBsAg) has previously been shown to occur in mice and humans through transplantation of bone marrow cells from donors immunized against HBsAg (anti-HBs) to non-immune recipients. In the present study we evaluated the effect of adoptive transfer of immunity to HBsAg on the growth of HbsAg-secreting hepatocellular carcinoma (HCC) xenografts in athymic mice. METHODS: Immunocompetent mice were immunized with recombinant HBsAg. Bone marrow cells from anti-HBs+ mice were injected intravenously to irradiated athymic Balb/c mice which had been previously transplanted subcutaneously with Hep3B human hepatoma cells. Treatment groups included mice receiving bone marrow transplantation from HBV-immunized (anti-HBs positive) and non-immunized (anti-HBs negative) donors. RESULTS: At 9 weeks post bone marrow transplantation, tumor volume and serum alpha-fetoprotein levels in athymic mice receiving HBV-immune bone marrow cells were 11.5 mm3 and 363 ng/ml, respectively, as compared to 1579 mm3 and 19,000 ng/ml, in recipients of non-immune bone marrow transplantation (p<0.005). T-cell depletion of antiHBs+ immune bone marrow prior to transplantation decreased the anti-tumor effect but did not abolish it. A mild nonspecific, bone marrow-derived, graft versus tumor effect was observed in mice transplanted with human hepatoma cells that do not express HBsAg. CONCLUSIONS: Adoptive transfer of immunity to HBV facilitates suppression of experimental human HCC expressing HBsAg. This effect is the result of a combination of specific anti-viral surface antigen effect and a nonspecific graft versus tumor effect.

41]Lau GK, Liang R, Lee CK, Yuen ST, Hou J, Lim WL, Williams R. Clearance of persistent hepatitis B virus infection in Chinese bone marrow transplant recipients whose donors were anti-hepatitis B core- and anti-hepatitis B surface antibody-positive. J Infect Dis 1998 Dec;178(6):1585-91

Thirteen hepatitis B surface antigen-positive Chinese patients who received hepatitis B surface antibody-positive marrow (hepatitis B core antibody-positive or -negative: 6 and 7, respectively) via allogeneic bone marrow transplantation (BMT) were studied. After BMT, 4 recipients had serologic clearance of hepatitis B surface antigen from hepatitis B core antibody-positive marrow, but none of the recipients of hepatitis B core antibody-negative marrow had serologic clearance (P=.02). There was no significant difference in the donors' hepatitis B surface antibody titer before BMT for patients with or without serologic clearance of hepatitis B surface antigen (2255.2+/-4244.0 vs. 854.2+/-2306.7 mIU/mL; P=not significant). Adoptive immunity clearance of hepatitis B surface antigen was favored by hepatitis B core antibody positive-donor marrow and was not related to donor pre-BMT hepatitis B surface antibody titer.

42]Lau GK, Yuen ST, Au WY, Wu PC, Liang R. Histological changes during clearance of chronic hepatitis B virus infection by adoptive immunity transfer. J Gastroenterol Hepatol 1999 Mar;14(3):262-8

BACKGROUND: Serological clearance of hepatitis B surface antigen (HBsAg) has been described after reception of hepatitis B surface antibody positive marrow, via allogeneic bone marrow transplantation (BMT). Histological changes during the clearance of HBsAg are unknown. METHODS AND RESULTS: We described two chronic hepatitis B carriers (both hepatitis B e antigen negative), who cleared HBsAg after allogeneic bone marrow transplantation. Both received hepatitis B surface and core antibody positive human leucocyte antigen identical donors' marrow and had serological clearance of HBsAg 15 and 7 weeks after allogeneic BMT, respectively. Both events were preceded by hepatic flare. Both patients were also treated with famciclovir for the prevention of hepatitis B reactivation after BMT. Histological examination during the flare showed only mild necroinflammatory activity with multiple foci of confluent necrosis, associated with moderate lymphocytic infiltration. The majority of these lymphocytes were cluster of differentiation (CD) 8 positive. Using immunohistochemistry, there was no detectable hepatic expression of hepatitis B core antigen. However, HBsAg was positive, mainly in the area of confluent necrosis. Using in situ hybridization, hepatitis B virus (HBV) DNA was detected in the nucleus of 5% of hepatocytes, but not in the cytoplasm. CONCLUSIONS: At their last follow up, 22 and 16 months after BMT, the serum of both patients remained HBsAg negative, hepatitis B surface antibody positive and HBV-DNA negative by branched DNA assay.

43] Ilan Y, Nagler A, Zeira E, Adler R, Slavin S, Shouval D.Maintenance of immune memory to the hepatitis B envelope protein following adoptive transfer of immunity in bone marrow transplant recipients. Bone Marrow Transplant 2000 Sep;26(6):633-8

Adoptive transfer of immunity against hepatitis B surface antigen (HBsAg) has been documented in mice and humans. In the present study, we report long-term follow-up of antibodies to HBsAg in humans who received allogeneic bone marrow transplantation (BMT) from donors immunized with HBsAg. BM donors were immunized with recombinant HBsAg. BM or PB cells were transplanted to HLA matched recipients. Recipients were followed for anti-HBs seroconversion. Control groups included non-immunized or rHBsAg immunized healthy adults as well as individuals that had had hepatitis B and recovered spontaneously. PBLs were stimulated in vitro with rHBsAg and stimulation was expressed as stimulation index. Adoptive transfer of immunity to HBsAg was initially documented in 12 recipients of BM from anti-HBc+/anti-HBs+ donors. An almost 4 year follow-up showed detectable protective anti-HBs levels (>10 mIU/ml) in 50% of patients. Immunity to HBV was also documented in 22/35 BMT recipients (62%), who received their bone marrow from actively immunized donors. In 7/9 of these BMT recipients, anti-HBs antibodies levels were documented 25 months following BMT. In 6/8 (75%) of patients who received only PBLs from HBV immune donors, adoptive transfer of immunity to HBV, and seroconversion to HBsAg+, were documented within 2 months of i.v. injection. Evidence for specific cellular immune response with increased SIs was documented for healthy vaccinees, and BMT recipients, and in none of the healthy non-vaccinated controls. These results suggest that adoptive transfer of immunity to HBV is a useful method for providing long-lasting protection for BM recipients.

44]Bocher WO, Dekel B, Schwerin W, Geissler M, Hoffmann S, Rohwer A, Arditti F, Cooper A, Bernhard H, Berrebi A, Rose-John S, Shaul Y, Galle PR, Lohr HF, Reisner Y. Induction of strong hepatitis B virus (HBV) specific T helper cell and cytotoxic T lymphocyte responses by therapeutic vaccination in the trimera mouse model of chronic HBV infection. Eur J Immunol 2001 Jul;31(7):2071-9

Humanized BALB/c mice (termed trimera mice) conditioned by lethal total body irradiation and bone marrow transplantation from SCID mice have been described to support rapid engraftment of human peripheral blood mononuclear cells (PBMC) and the induction of strong B and T cell responses after immunization in vivo. Moreover, these mice can be infected with the hepatitis B and C viruses (HBV, HCV). The current study employed this model to study therapeutic vaccination approaches against the HBV. Thus, strong primary Th cell responses against the HBV core (HBc) and the Borrelia burgdorferi control antigen were induced by transfer of antigen-loaded dendritic cells together with autologous PBMC from HBV-naive donors as well as by vaccination with high doses of antigen or a DNA plasmid encoding for HBcAg. Moreover, primary peptide-specific CTL responses against the immunodominant epitope HBc(18 - 27) were induced by HBc particle or DNA vaccination of chimera engrafted with HBV-naive PBMC. Finally, strong HBc-specific Th cell and antibody responses were induced by HBc or DNA vaccination of mice reconstituted with PBMC from a chronic HBV patient. Thus, since HBc represents the immunodominant antigen in self-limited HBV infection, HBc particles or DNA vectors are good candidates for therapeutic vaccination, that will be further studied in our model and clinical studies.

45] Lau GK, Suri D, Liang R, Rigopoulou EI, Thomas MG, Mullerova I, Nanji A, Yuen ST, Williams R, Naoumov NV.Resolution of chronic hepatitis B and anti-HBs seroconversion in humans by adoptive transfer of immunity to hepatitis B core antigen.Gastroenterology 2002 Mar;122(3):614-24

BACKGROUND & AIMS: Impaired T-cell reactivity is believed to be the dominant cause of chronic hepatitis B virus (HBV) infection. We characterized HBV-specific T-cell responses in chronic hepatitis B surface antigen carriers who received bone marrow from HLA-identical donors with natural immunity to HBV and seroconverted to antibody to hepatitis B surface antigen. METHODS: T-cell reactivity to HBV antigens and peptides was assessed in a proliferation assay, the frequency of HBV core- and surface-specific T cells was quantified directly by ELISPOT assays, and T-cell subsets were analyzed by flow cytometry. RESULTS: CD4+ T-cell reactivity to HBV core was common in bone marrow donors and the corresponding recipients after hepatitis B surface antigen clearance, whereas none reacted to surface, pre-S1, or pre-S2 antigens. Furthermore, CD4+ T cells from donor/recipient pairs recognized similar epitopes on hepatitis B core antigen; using polymerase chain reaction for the Y chromosome, the recipients' CD4+ T lymphocytes were confirmed to be of donor origin. The frequency of core-specific CD4+ and CD8+ T cells was several-fold higher than those specific for surface antigen. CONCLUSIONS: This study provides the first evidence in humans that transfer of hepatitis B core antigen-reactive T cells is associated with resolution of chronic HBV infection. Therapeutic immunization with HBV core gene or protein deserves further investigation in patients with chronic hepatitis B.