HBV Vaccine in Anti-core Positive Donors After LT
HBV Vaccine in Anti-core Positive Donors After LT
Anti-HBc positive liver donors frequently have occult HBV infection, and several studies in
 HBsAg-negative subjects have shown that there is often the detection in the liver of
 covalently closed circular DNA (cccDNA). In the setting of liver transplantation and
 immunosuppresion, grafts from antiHBc positive donors may cause de novo HBV infection
 (defined by the development of positive HBsAg and/or detectable serum or liver HBV DNA in
 previously HBsAg recipients).

 Active immunization may be successful in up to 20% of patients who received an anti-HBc+
 liver during transplantation after the first vaccination schedule, and up to 30% after a
 second vaccination course. Responders to vaccination could safely halt nucleos(t)ide analog
 prophylactic therapy with no risk of HBV reactivation during follow-up.

 We also hypothesize that an impaired antigen-specific adaptive cell-mediated immunity at
 baseline explain the lack of response

 Primary objective:

 1. To investigate the efficacy of HBV vaccination in liver transplant recipients who
 received a liver from an anti-HBc positive donor.

 2. To assess the safety of nucleos(t)ide treatment interruption in those patients achieving
 a response to HBV vaccination
HYPOTHESIS The hypothesis of the study is that active immunization may be successful in up to
 20% of patients who received an anti-HBc+ liver during transplantation after the first
 vaccination schedule, and up to 30% after a second vaccination course. Responders to
 vaccination could safely halt nucleos(t)ide analog prophylactic therapy with no risk of HBV
 reactivation during follow-up.

 Thus, an impaired antigen-specific adaptive cell-mediated immunity at baseline may explain
 the lack of response.

 OBJECTIVES

 Primary objective:

 1. To investigate the efficacy of HBV vaccination in liver transplant recipients who
 received a liver from an anti-HBc positive donor.

 2. To assess the safety of nucleos(t)ide treatment interruption in those patients achieving
 a response to HBV vaccination

 Secondary objectives:

 1. To investigate which clinical and virological variables are associated with a protective
 response to HBV vaccination (including time from liver transplant, type of
 immunosuppressive therapy and vaccination prior liver transplantation)

 2. To assess the role of HBV specific CD8 responses in developing a protective response to
 vaccination

 3. To assess the relationship between intrahepatic cccDNA-HBV levels and the outcome after
 vaccination

 STUDY DESIGN This is a multi-center, open-label study in liver transplant recipients.
 Four transplant centers will include non-HBV liver transplant recipients who received a
 graft from an HBV anti-core positive donor. All patients should be under prophylactic
 nucleos(t)ide treatment (NA). Individuals will undergo HBV vaccination with double dosis
 vaccine (40 ug) and protective response will be evaluated at the end of a first course
 of vaccination. Response will be defined as anti-HBs levels > 100 IU/L. In patients who
 do not respond to a first course of vaccination, a second course will be administered.

 In patients achieving a protective immune response, prophylactic NA treatment will be
 interrupted and follow-up will be extended until 2 years after treatment interruption.
 Among those patients achieving vaccination response, a booster dose will be given if
 antiHBs levels fall below 100 IU/L during follow-up.

 Sample size calculation Sample size has been calculated in order to be able to identify
 variables that able to predict response/non response. The estimated number of anti-core
 positive recipients in all centers according to anti-core prevalence in general
 population is 160 patients (40 patients/center). According to previous reported data,
 around 20% would achieve a response to a first course of vaccination and an additional
 30% would achieve response after a second course. With a confidance interval of 95% and
 accepting a precision level of 5% and an estimated loss rate of 15%, the calculated
 sample size would be 114 patients.

 Study flowchart All patients will receive 40 ug of HBV vaccine, at 0, 1 and 3 months
 time points.

 In patients not achieving protective anti-HBs titers (≥ 100 IU/L) 1 month after the last
 HBV vaccine dose, the same vaccine schedule will be repeated (40 ug of vaccine 0, 1 and
 3 months).

 Patients not achieving protective anti-HBs titers (≥ 100 IU/L) 1 month after last HBV
 vaccine dose will be considered non-responders and will continue on NA therapy.

 In patients achieving protective anti-HBs titers, prophylaxis with nucleoside analogues
 will be interrupted and patients will be followed for a minimum period of 24 months.
 Blood tests will be performed every 6 months including liver tests, markers of HBV
 reactivation and anti-HBs. If anti-HBs levels fall below <100 IU/L at any time point of
 follow-up, a single boost (40 ug) will be repeated.

 In case of HBV reactivation (HBsAg or HBV-DNA positive) during follow-up, oral NA
 therapy will be restarted with high barrier to resistance drugs such as entecavir or
 tenofovir.

 Study procedures All patients Screening visit

 -  Medical history and physical examination.

 -  Review inclusion and exclusion criteria.

 -  Obtain written informed consent.

 -  Complete blood tets

 -  Hematology, chemistry and coagulation tests.

 -  Serologies: HBsAg, IgG HBV anti-core (HBc), anti-HBs, HIV antibody, IgG HCV

 -  HBV-DNA, HCV-RNA (only if anti-HCV positive)

 -  Liver biopsy (if the patient signs an additional inform consent)

 -  Extraction of 40 ml of blood to process PBMC (Hospital Clínic Barcelona and Padova
 University Hospital)

 -  Liver Biopsy (Hospital Clínic Barcelona) in order to exclude the presence of liver
 fibrosis (or other lesions) and to obtain frozen tissue and evaluate the presence
 of cccDNA and its correlation with study outcomes.

 Baseline (day 1):

 The following procedures will be completed prior to treatment administration:

 -  Perform a complete physical examination.

 -  Extraction of 40 ml of blood to process PBMC Thereafter, the first dose of vaccine
 (GSK 40 ug) will be administered Week 4: 2nd dose of vaccine Week 12: 3rd dose of
 vaccine

 Week 16:

 -  Medical history and physical examination.

 -  Complete blood tets

 -  Hematology, chemistry and coagulation tests.

 -  Serologies: HBsAg, anti-HBc, anti-HBs,

 -  HBV-DNA

 -  Extraction of 40 ml of blood to process PBMC (Hospital Clínic Barcelona and Padova
 University Hospital) a) Responders If anti-HBs ≥ 100 IU/L Interruption of
 nucleoside analogue* (in patients who qualify for NA interruption, a specific
 follow-up will continue, as described below) b) Non-responders If anti-HBs < 100
 IU/L First dose of second course of vaccination Week 20: 2nd dose of vaccine Week
 32: 3rd dose of vaccine

 Week 38:

 -  Medical history and physical examination.

 -  Complete blood tets o Hematology, chemistry and coagulation tests.

 o Serologies: HBsAg, anti-HBc, anti-HBs,

 o HBV-DNA

 -  Extraction of 40 ml of blood to process PBMC (Hospital Clínic Barcelona and Padova
 University Hospital)

 1. Responders If anti-HBs ≥ 100 IU/L Interruption of nucleoside analogue (in
 patients who qualify for NA interruption, a specific follow-up will continue,
 as described below)

 2. Non-responders If anti-HBs < 100 IU/L will continue NA therapy

 -  Responders to vaccination and NA withdrawal: follow-up every 2 months
 during the first 6 months and every 6 months until 2 years of follow-up

 At each visit:

 Medical history and physical examination.

 Complete blood tets:

 o Hematology, chemistry and coagulation tests.

 -  Serologies: HBsAg, Anti-HBs

 -  HBV-DNA If anti-HBs < 100 IU/L : a vaccine booster (40 ug) will be administered If
 HBsAg+ or HBV-DNA+ confirmed in two occasions 2 weeks apart: NA therapy with
 entecavir or tenofovir will be introduced.

 Statistical analysis Statistical analysis will be performed using SPSS, version 22
 (SPSS, Chicago, IL). Categorical data will be analyzed using the chi-square test;
 continuous data will be analyzed using the Student T test. The survival rates were
 calculated using the Kaplan-Meier method with log- rank test for significance. A P value
 of<0.05 will be considered
Inclusion Criteria:

 -  Age between 18 and 75 years- old.

 -  HBsAg-negative pre-transplantation

 -  Liver transplant recipients; more than 2 years from the date of LT

 -  Transplantation of a graft from an HBV anti-core positive donor

 -  Patients should be under nucleoside analogue therapy with Lamivudine, Tenofovir or
 Entecavir

 -  Stable immunosuppressive therapy during the last 6 months

 -  Baseline anti-HBs levels <100 IU/L (HBV vaccination while on the waiting list is
 allowed and will be recorded)

 -  Willingness to participate in the study and written inform consent

 Exclusion Criteria:

 -  • HBsAg positive at any time post-transplantation

 -  HBV-DNA positive at any time post-transplantation

 -  Any HBIG dose during the last 12 months

 -  HBV vaccination after liver transplantation

 -  Spontaneous or vaccine-induced post-transplant anti-HBs titers ≥ 100 UI/L

 -  Any rejection episode during the last 12 months

 -  Positive HCV-RNA at time of vaccination

 -  HCV therapy with direct acting antivirals within the previous 12 months

 -  HIV coinfection

 -  Advanced fibrosis after LT (liver stiffness measurement ≥ 9.5 kPa)

 -  Pregnancy