SHORT REPORT

Immunization With an Adjuvant Hepatitis BVaccine in Liver Transplant Recipients:Antibody Decline and Booster Vaccination WithConventional VaccineMatthias Gunther,1 Ruth Neuhaus,2 Tanja Bauer,3 Wolfgang Jilg,3 Jan Arne Holtz,1 and Ulrich Bienzle1

1Institute of Tropical Medicine, Humboldt University, Berlin, Germany; 2Department of General, Visceral andTransplantation Surgery, Charite, Humboldt University, Berlin, Germany; and 3Institute for MedicalMicrobiology and Hygiene, University of Regensburg, Regensburg, Germany

Patients after orthotopic liver transplantation (OLT) due to hepatitis B virus (HBV)-related disease are at risk ofendogenous hepatitis B reinfection and may receive life long prophylaxis with hepatitis B hyperimmunoglobulin(HBIG). In a previous study 16 of 20 OLT patients were immunized successfully with an adjuvant hepatitis B vaccine.To maintain protective antibody levels under immunosuppressive therapy, 11 of these patients were revaccinatedwith a double dosed conventional hepatitis B vaccine. Median interval between last vaccination and booster was 24months (range 22-31 months). Antibody titres against hepatitis B surface antigen (anti-HBs) were monitored at the dayof booster vaccination (day 0), at day 7 and day 28. At day 0, all vaccinees but one had anti-HBs titres greater than500 IU/L (median 1,925 IU/L, range 196-7,612 IU/L). Maximum antibody titres after previous vaccination declined by amedian of 82% (range 47-96%). After booster vaccination the anti-HBs titre increased significantly by a median factorof 2.42 (P <0.05). In conclusion, the majority of liver transplant recipients who previously had responded to adjuvanthepatitis B vaccine exhibited sufficient immunocompetence to produce a substantial antibody response after boosterimmunization with a conventional vaccine. Liver Transpl 12:316-319, 2006. © 2006 AASLD.

Received August 18, 2005; Accepted October 25, 2005.

Patients after orthotopic liver transplantation (OLT) dueto hepatitis B-related disease are at risk of endogenousHBV reinfection. They need life long prophylaxis withhepatitis B hyperimmunoglobulin (HBIG), which is safebut unpleasant and very expensive.1,2

Independently, Barcena et al.3 and Sanchez-Fueyo etal.4 immunized OLT patients with commercially avail-able hepatitis B vaccine after discontinuation of HBIGprophylaxis and reported seroconversion rates (� 10IU/L anti-HBs) of 80% and 64%, respectively. However,Angelico et al.5 were unable to reproduce these find-ings, (17.6%; � 10 IU/L anti-HBs), and in a more recentimmunization study with double dosed hepatitis B

standard vaccine by Lo et al.6 in transplant recipientsreceiving lamivudine prophylaxis, a response rate ofless than 8 % and rapidly declining antibody levels wereobserved.

As a rule, titres above 10 IU/L are considered protec-tive in immunocompetent subjects, and above 100 IU/Lin immunosuppressed patients. A trough level greaterthan 500 IU/L prevents reinfection in almost 100% ofHBeAg-negative patients.7

Using an adjuvant hepatitis B vaccine (HBsAg-AS02),which contained 3-deacylated monophosphoryl lipid A(MPL) and purified natural saponin from Quillajasaponaria Molina (QS21) in an oil/water emulsion, we

Abbreviations: OLT, Orthotopic liver transplantation; HBV, Hepatitis B virus; HBIG, Hepatitis B hyperimmunoglobulin; HBeAg,Hepatitis B e antigen; Anti-HBs, Antibody against hepatitis B surface antigen; AS02, Adjuvant system containing MPL and QS21; MPL,Monophosphoryl lipid A; QS21, Quilla saponaria Molina adjuvant; HBsAg, Hepatitis B surface antigen.Supported by GlaxoSmithKline Biologicals (Rixensart, Belgium) who provided the vaccine.Address reprint requests to Dr. Matthias Gunther, Institute of Tropical Medicine, Charite, Humboldt University, Spandauer Damm 130, 14050 Berlin,Germany. Telephone: (49) 30 30116800; FAX: (49) 30 30116888; E-mail: matthias.guenther@charite.de

DOI 10.1002/lt.20674Published online in Wiley InterScience (www.interscience.wiley.com).

LIVER TRANSPLANTATION 12:316-319, 2006

© 2006 American Association for the Study of Liver Diseases.

achieved significant anti-HBs titres in 16 of 20 OLTrecipients who were HBsAg-positive and HBV DNA neg-ative before transplantation (median maximum anti-HBs concentration 25,343.5 IU/L, range 1,255-83,121IU/L).8,9 Participants remained on HBIG prophylaxisduring the trial.

The adjuvant hepatitis B vaccine has not yet beenlicensed. Therefore, we decided to reimmunize our pa-tients with a standard HBV vaccine to find out if boos-tering is possible and if so to which extent. Our studyaddresses two questions: First, how rapid is the rate ofantibody decline, and second, can persisting HBsAg-AS02-induced anti-HBs titres be boostered by admin-istration of hepatitis B standard vaccine?

PATIENTS AND METHODS

Ten males and one female of the 16 successful respond-ers to HBsAg-AS02 immunization (� 500 IU/L anti-HBs)8,9 participated. The other five patients, who stillhad antibody titres � 500 IU/L, were not available orrefused to participate. All study participants but one,who underwent transplantation for liver failure due toacute hepatitis B, suffered from HBV-cirrhosis. Beforetransplantation they were HBsAg positive and HBVDNA negative.

HBIG prophylaxis at study entry had been discontin-ued for a median of 25.5 months (range 22-34 months).

Eight patients received tacrolimus for immunosuppres-sion, two of them in combination with mycophenolatemofetil and the other three were on cyclosporin A mono-therapy.

Participants were boostered with a double dosed (2.0ml) intradeltoidal vaccination of hepatitis B standardvaccine (Engerix™, GlaxoSmithKline Biologicals Rixen-sart, Belgium). Four healthy individuals (two men andtwo women) who had a complete course of hepatitis Bimmunization served as controls. The trial protocolconformed to the ethical guidelines of the Declaration ofHelsinki. Anti-HBs titres were determined by commer-cial enzyme-linked immunoassay (AUSAB EIA, Abott,Chicago, IL) before booster vaccination (day 0), at days7 and 28. The Wilcoxon rank test and the Mann-Whit-ney U test were applied using SPSS software version11.0 (SPSS, Chicago, IL).

RESULTS

The median age of study participants and healthy con-trols was 57.0 years (range 43-67 years) and 58.5 years(range 43-64 years), respectively. Median interval be-tween last vaccination with adjuvant vaccine andbooster vaccination was 24 months (range 22-31months) in patients, and longer than 5 years in con-trols. At day 0 all AS02 vaccinees but one (No. 10; 196IU/L anti-HBs) still had titres above 500 IU/L anti-HBs

TABLE 1. Characteristics and Anti-HBs Titres of 11 OLT Patients Who Underwent Hepatitis B Booster Vaccination

With Double Dosed Standard Vaccine

Patient*

Age, Gender

Interval Max

Titer/Day0°

Max Anti-HBs

Titer (IU/L)

Anti-HBs

(IU/L)

Day 0

Anti-HBs

(IU/L)

Day 7

Anti-HBs

(IU/L)

Day 28

0254, m

25 17,729 3,325 4,200 8,172

0560, m

23 50,918 1,925 11,312 8,617

0847, m

22 29,509 3,727 4,099 9,009

0957, m

18 29,047 7,612 82,150 55,600

1060, m

27 1,287 196 180 520

1143, m

30 21,640 4,126 3,849 3,968

1467, m

31 44,549 4,758 4,403 5,212

1652, m

22 7,323 1,497 5,169 3,981

1758, m

21 13,155 1,408 2,404 2,256

1863, f

20 1,255 659 780 937

1944, m

23 7,683 1,362 1,433 2,414

*Number of patient in previous study (Bienzle et al., 2003).†Interval between maximum titer and booster (months).

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(see Table I), defined as protective lower limit in theprevious study.9 A median decline of antibody titres by82.3% (range 47.5-96.2%) to a median anti-HBs con-centration of 1,925 IU/L (range 196-7,612 IU/L) wasfound. Before vaccination the median of anti-HBs con-centration in controls was 243.5 IU/L (range 1-344IU/L).

At day 28 after booster vaccination, anti-HBs titres inthe patients had increased by a factor of 2.42 (median,range 0.96-7. 30; P � 0.05) to a median titre of 3,981IU/L (range 520-55,600 IU/L), and in the controls by afactor of 84.14 (median, range 22.09-128.33) to a me-dian titre of 16,300 IU/L (range 536-34,520 IU/L). Al-ready, at day 7 we observed an antibody increase inpatients by a factor of 1.18 (median, range 0.92-10.79;P � 0.05) to a median titre of 4,099 IU/L (range 180-82,150 IU/L) and in controls by a factor of 10.85 (me-dian, 0.76-103) to a median titre of 374 IU/L (range103-5,241 IU/L) (Fig. 1).

DISCUSSION

Response rates after primary hepatitis B immunizationin OLT recipients are low (7% and 23%, respectively),and even lower after transplantation for hepatitis B-related disease.9,10 In case of successful immunization,the antibody concentrations in patients on immuno-suppressive therapy tend to decrease rapidly.7,11

Recently, we have shown that successful immuniza-tion can be achieved with an adjuvant hepatitis B vac-cine in OLT recipients.8,9 The vaccine exerts a B- andT-cell response which is strong enough to induce sus-tained anti-HBs production. We have now retested 11 ofthese patients, and after a period of about 2 years (me-dian 23 months) from maximum titre to the date ofbooster vaccination titres were still in the protective

range (median 1,925 IU/L anti-HBs). We had expectedto find a more rapid antibody decline. However, com-pared to the decrease reported in healthy individualsthe transplant recipients fared extremely well.12,13 Weassume, that the set of novel adjuvants induces a pro-found and long-lasting immune response. There mayalso be some boostering by minute amounts of endog-enously produced HBsAg.

The need of booster vaccinations in healthy individ-uals after successful primary immunization has beenquestioned.14 However, immunosuppressed individu-als may benefit from regular boosters to maintain pro-tective titers.15 In our study, 10 of the 11 patientsshowed a positive response but we found a muchweaker booster effect in patients than in healthy con-trols. It has to be kept in mind that booster immuniza-tion was performed with a standard HBV vaccine whichrarely induces a significant antibody response in pa-tients on immunosuppressive treatment. Immunosup-pressive agents such as cyclosporin and tacrolimus in-terfere with T-cell activation and memory T-cellgeneration, thereby controlling the expansion of mem-ory Th cells upon antigen challenge.16,17 Moreover, thebooster effect in individuals with high antibody titresmay be lower than in subjects with low residual titres.

Immunization with standard HBV-antigen coupled topotent adjuvants can elicit highly protective anti-HBstiters.8,9 This follow-up study shows that the antibodydecline is similar to the one in healthy individuals, andthat booster immunization with a standard vaccine pro-duces a satisfactory response. If booster vaccinationsare applied before the titres fall below the protectivelevel (100 IU/L anti-HBs), the patients may never haveto resume HBIG reinfection prophylaxis. Confirmationof our findings should be obtained in a larger controlledstudy.

Figure 1. Effect of booster vaccination in patients (n � 11) and controls (n � 4): median anti-HBs titres at day 0 (light shading),day 7 (medium shading), and day 28 (dark shading); (N) Number of patient in previous study.9

318 GUNTHER ET AL.

LIVER TRANSPLANTATION.DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases

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