Low TLC and elevated SGOT/SGPT after Liver transplant

Dear Sir,
   Four months back I had liver transplant done, due to HBV related Cirrhosis. Till two months back I was treated with two antiviral drugs(entacavir 0.5mg and tenofovir 300mg) and prograf, cellcept wysolone etc. Two months back entacavir was withdrawn and I am now treated with tenofovir, prograf(6mg), cellcept(1000mg) and Magnesium suppliment. Almost at the same time( 2months back) I suffered from maleria (malaria) also.
Since then SGOT and SGPT are gradually rising from normal level, and they are now 69 and 46 level( normal range is 4) and rose to 3.2 almost one month back but it goes down to 2.3 now.
What could be reason? Is it showing sign of HBV recurrance or is it any sign of rejection?
Please note that when I was taking antiviral treatment before the transplant I took Lamivudine and entacavir.
I would greatly appreciate your comment on my condition.
Best regards,
Pbala

[Thomas D Schiano, MD]

i doubt the liver test abnormalities are due to HBv as tenofovir works very well without resistance.  it could be a touch of fatty liver or rejection.  as long as the bilirubin level is normal i think you can follow the lab tests expectantly.

sorry for the delay in responding--there was a glitch in the system

[p_bala]

Dear sir,
   Thank you for your comment.
   The day I posted this problem, I visited my doctor. He prescribed to drop cellcept and to start wysolone 10mg daily. The test on 21st Nov shows TLC increased to normal range (5500 from 2200). Other liver engymes are also back to the normal range. Right now I am on prograf as only immunosupressant.
On 8th Nov I got tested my blood for HBV DNA the results and its interpretations are given in the report as follows
---------------------------------------------------------------------
| HEPATITIS B VIRAL (HBV              <20 IU/ml |
| DNA), QUANTITATIVE REAL                         |
| TIME PCR                                                   |
|(Real Time PCR using Cobas                         |
| Ampliprep & TaqMan)                                   |
---------------------------------------------------------------------
Interpretation
--------------------------------------------------------------------------------------------------
|RESULT in IU/mL    |        COMMENTS                                         |
|-----------------------------|---------------------------------------------------------------------|
|Target not detected |    Sample provided does not contain HBV DNA |
|-----------------------------|-------------------------------------------------------------------|
|=20 to 1.7 x 10^8  |HBV DNA detected within the linear range of |
|                             |the assay                                                   |
|-----------------------------|-----------------------------------------------------------------|
|>=1.7 x 10^8          |HBV DNA detected above the linear range of |
|                             |the assay                                                   |
------------------------------------------------------------------------------------------------
Note:
1. Linear reporting range of the assay is 20 - 1.7 x 10^8IU/mL
2. Conversion factor: 1 IU/mL = 5.82 copies / mL
3. Test conducted on Serum / Plasma
4. This test is not intended for use as a screening test for the
presence of HBV in blood or blood products or as a diagnostic
test to confirm the presence of HBV infection.
5. HBV genotyping and Drug resistance is recommended in positive
cases.
----------------------------------------------------------------------------------------------------

Now my questions are
1) Is only one immunosupressant is sufficient or again cellcept to be started. If cellcept started and TLC goes low, what will be the next course of action.
2) The DNA result shows DNA is positive(2months back the same test showed "Target not detected'), though the level are very low. Does that mean the virus started multiplying and damaging liver?
Thanks and regard,
pbala

[Thomas D Schiano, MD]

from the data that i have the HBV appears undetectable which is good.  The immunosuppression would be fine as monotherapy.

[p_bala]

Dear Sir,
mistakenly I did not put the interpretation for <20IU/mL. Please find it below. It says the DNA is detected. Though level is very low.
Do you interprete it same as DNA non detectable?

Interpretation
---------------------------------------------------------------------------------------------------------
|RESULT in IU/mL     |       COMMENTS                                              |
|------------------------------|------------------------------------------------------------------------|
|Target not detected  |   Sample provided does not contain HBV DNA     |
|------------------------------|------------------------------------------------------------------------|
|   <20                     |    HBV DNA detected,but below the lower limit of |
|                              |    linear range of the assay. These results           |
|                              |    should be interpreted with caution                   |
|------------------------------|------------------------------------------------------------------------|

[Thomas D Schiano, MD]

yes--I would consider it as undetectable