Impact of Double-Filtration Plasmapheresis in Combination with Interferon and Ribavirin in Living Donor Liver Transplant Recipients with Hepatitis C

Abstract

Double-filtration plasmapheresis (DFPP) selectively removes high molecular weight substances including hepatitis C virus (HCV). Four live donor liver transplantation (LDLT) recipients with HCV received combination therapy with low-dose interferon (IFN) and ribavirin with DFPP. Three patients underwent this therapy for prophylaxis of HCV recurrence, and one for treating fibrosing cholestatic hepatitis (FCH). The combination therapy and DFPP decreased HCV RNA levels to 8.2% ± 2.9% and 0.7% ± 0.5% by the 5^th and 30^th day of treatment, respectively. Three patients who underwent DFPP for prophylaxis showed no evidence of HCV recurrence for >1 year after treatment. The patient whose graft showed FCH, recovered dramatically after the DFPP treatment. DFPP appeared to be effective in reducing HCV viremia and preventing HCV recurrence in patients with high HCV RNA levels after LDLT. Moreover, it may become a rescue therapy for FCH in a liver transplant recipient with hepatitis C.

Immediately after transplantation and initiation of immunosuppression, a dramatic increase in the hepatitis C viral (HCV) RNA is observed in the transplant recipients with hepatitis C; in most patients, the amount of serum virions increase to >1000×10³ IU/ml by 1 month after transplantation (¹). Higher HCV RNA levels at the early posttransplant stage are reportedly associated with a more severe recurrence of hepatitis (²). Particularly, fibrosing cholestatic hepatitis (FCH), characterized by a high rate of viral replication and a relative paucity of inflammatory activity, shows a rapidly progressive liver failure resulting in poor prognosis (^{3, 4}). Some recent reports have mentioned that the risk of FCH might increase in living donor liver transplantation (LDLT) recipients (^{5, 6}). Additionally, the pretreatment viral titer is an important factor in the response to interferon (IFN) therapy (^{7, 8}); a higher pretreatment titer predicts a lower chance of complete response to IFN.

Double-filtration plasmapheresis (DFPP), a newly developed apheretic technique, selectively removes high molecular weight substances, including immunoglobulins and immune complexes (⁹); it has been widely and effectively used to eliminate autoantibodies from plasma. HCV exists in the circulatory system in various forms (e.g., free virions, immune complexes, and nucleocapsids) (¹⁰). The DFPP plasma filter has a 30-nm pore diameter; the free HCV viron diameter is 55–65 nm (¹¹). Sakai et al. reported the efficacy of immunoadsorption therapy to treat chimpanzees with chronic hepatitis C (¹²). Although there are no reports on DFPP being employed for this purpose in patients with hepatitis C, the use of DFPP might facilitate the prompt reduction of HCV viremia in transplant recipients with high HCV RNA levels, particularly in FCH patients. In four LDLT recipients with hepatitis C, we performed a combination therapy using IFN and ribavirin with DFPP treatment. Here, we describe a successful anti-HCV treatment in these four cases.

Patient characteristics are listed in Table 1. In three of the four cases, the regimen was employed prophylactically. FCH occurred in one case, and the procedure was employed to reduce the qualitative HCV RNA. The average follow-up period after the DFPP treatment was 15.5 months. The HCV genotype was 1b in three patients. The pretreatment HCV RNA levels ranged from 2000 to 3800×10³ IU/ml; the average level being 2660×10³ IU/ml. For the prophylaxis of HCV recurrence after LDLT, a combination therapy with low-dose IFN alfa-2b (Intron-A; Schering-Plough, Inc., Osaka, Japan), 1.5 MU subcutaneously once/day; and ribavirin (Rebetol; Schering-Plough, Inc., Osaka, Japan), 400 mg PO/day, was initiated when the following clinical conditions existed: white blood cell count was >3000 cells/mm³; platelet count, >50,000/mm³; and hemoglobin level, >9.0 g/dL, and the patient could tolerate the therapy. In case 3, the standard combination therapy of IFN alfa-2b and ribavirin was initiated from 28 postoperative day (IFN alfa-2b 3 MU subcutaneously once/day; and ribavirin 400 mg PO/day). However, due to IFN-related side effects, such as leukopenia and depression, the treatment was discontinued. On day 181 after LDLT, the combination therapy was restarted using low-dose IFN and DFPP. In case 4, despite an attempt to treat HCV recurrence with the standard combination therapy using IFN alfa-2b and ribavirin from 42 postoperative day (IFN alfa-2b 3 MU subcutaneously once/day; and ribavirin 400 mg PO/day), the patient showed FCH with a high HCV RNA level; therefore, IFN-beta (Feron; Daiichi Parma Inc., Tokyo, Japan), 6 MU once/day, was administered. DFPP was performed on all the first 5 days of the drug therapy. Plasmaflow (Asahi Kasei Medical Co., Ltd. Tokyo, Japan) was used as the primary membrane of plasmapheresis; and Cascadeflo (Asahi Kasei Medical Co., Tokyo, Japan), as the secondary membrane for DFPP. Plasma (60 ml/kg) was treated during each DFPP session. The blood and plasma flow were 100 ml/min and approximately 20 ml/min, respectively. Ideally, the DFPP treatment should not be performed >5 times. After the procedure, fresh frozen plasma (FFP) was infused (4 U/day) to supply the coagulant factors. DFPP was not performed, if the fibrinogen level before the procedure was <100 mg/dL; therefore, in cases 1 and 2, DFPP was skipped once. In case 3, DFPP was performed only twice due to a double lumen catheter related line infection. IFN was administered daily until the fifth day and three times a week thereafter. Three patients who underwent prophylactic therapy were treated immediately after LDLT according to our standard immunosuppression protocol, which included administration of tacrolimus (Prograf; Astellas Pharma Inc., Tokyo, Japan); basiliximab (Simulect; Novartis Pharma Inc., Tokyo, Japan); steroids; and mycophenolate mofetil (Cellcept; Chugai Pharma Inc., Tokyo, Japan). By 1 month after transplantation, steroids were tapered from 20 mg/week to 5 mg/week and discontinued. Tacrolimus was given at a dosage to maintain trough levels of 10 to 15 ng/ml during the first 3 weeks and 5 to 10 ng/ml thereafter. Basiliximab was given at 20 mg both just after transplantation and 4 days after transplantation. In case 4, immunosuppression therapy, which consisted of tacrolimus, steroids, and mycophenolate, was stopped immediately after FCH diagnosis, although it had been started just after LDLT.

TABLE 1: Patient demographics

During DFPP treatment, blood counts, liver function tests, and coagulant factors remained normal, but the platelet count and fibrinogen level did not (Table 2). The mean platelet and fibrinogen levels dropped to 88.8%±1.9% and 57.4%±1.6% of initial value, respectively. There was no difference in the reduction rate of either the platelet count or the fibrinogen level among the DFPP sessions.

TABLE 2: Pre and Post DFPP data

The dynamics of HCV RNA level in each patient within 30 days after DFPP are illustrated in Figure 1. In the first 5 days, the mean HCV RNA level dropped to 8.2%±2.9% of the pretreatment values. By 30 days after the initiation of the treatment, the mean HCV RNA level decreased to 0.7%± 0.5% of the initial value in all cases. In case 1, no evidence of HCV viremia is observed >1 year after the treatment. Three patients who underwent DFPP for prophylaxis showed normal liver function and no evidence of HCV recurrence in liver biopsy performed during the follow-up; however, a low HCV RNA level was confirmed in cases 2 and 3. After the DFPP treatment in case 4, the HCV RNA level decreased from 3100×10³ to 14×10³ IU/ml by 1 month, and the histopathological findings in the liver biopsy showed the remission of FCH, followed by an improvement of liver function (alanine aminotransferase level decreased from 150 to 50 IU/L; total bilirubin level from 8 to 3 mg/dL in 1 month). During this follow-up, the patient did not show FCH exacerbation.

FIGURE 1.: Dynamics of HCV RNA level. The dynamics of HCV RNA level in each patient within 30 days after the DFPP treatment.

In this small pilot study on LDLT recipients with high HCV RNA levels, DFPP contributed to the prompt reduction of HCV viremia to less than 10% and 1% of the initial level within the first 5 days and 1 month after the initiation of the treatment, respectively. Furthermore, 3 patients who underwent DFPP for prophylaxis showed no evidence of HCV recurrence in >1 year after the treatment. These findings suggest that a rapid decrease in the HCV RNA levels at the initiation of IFN therapy enables enhancing the overall response to IFN. Additionally, the patient whose graft showed FCH, recovered dramatically after the DFPP treatment.

The reported rate of major and significant complications related to DFPP is only 2.7%, which is comparable to the results of the plasma exchange treatment (¹³). Although an obvious reduction of fibrinogen level and a modest decrease in the platelet count was observed after an intensive course of DFPP treatment, Yeh et al. emphasized that low incidence of clinically important bleeding confirms the hemostasis related safety of DFPP (^{14, 15}). In our study, although the platelet counts and the fibrinogen levels were reduced to 10% and 40%, respectively, our patients showed no major side effects, such as bleeding.

In summary, DFPP appeared to be effective for reducing HCV viremia at the initiation of antiviral therapy and preventing HCV recurrence in patients with high HCV RNA after LDLT. A marked decrease in HCV-RNA viremia after DFPP at the initiation of IFN therapy may enhance the overall response of IFN. Moreover, it may become a rescue therapy for FCH in a liver transplant recipient with hepatitis C. Currently, a prospective study to examine the efficacy of DFPP for chronic hepatitis C patients is ongoing in Japan. Further, follow-up in larger cohorts is necessary to confirm our findings.