Antiviral prophylaxis against hepatitis B recurrence after liver transplantation: Current concepts

Abstract

The advance in treatment against hepatitis B virus (HBV) infection with the development of nucleos(t)ide analogues (NAs) with high genetic barrier to resistance, including entecavir and tenofovir, has improved clinical outcomes of patients transplanted for HBV infection, by preventing HBV recurrence after liver transplantation (LT) effectively. Currently, after LT, the combination of hepatitis B immunoglobulin (HBIG) and a high‐barrier NA is considered as the standard of care for prophylaxis against HBV recurrence. However, because of the high cost of intravenous high‐dose HBIG, other routes of HBIG administration, such as intramuscular or subcutaneous, have come to the foreground. In addition, several transplant centres tend to use a NA as monoprophylaxis, following a short post‐LT period of HBIG and NA combination. Lately, studies using HBIG‐free prophylactic regimens with entecavir or tenofovir have shown promising outcomes in preventing HBV recurrence, mostly regarding patients with undetectable HBV DNA at the time of LT. Although vaccination against HBV has been an attractive prophylactic approach, its efficacy has been controversial. Moreover, further studies are needed regarding long‐term outcomes of complete withdrawal anti‐HBV prophylaxis. For patients transplanted for HBV/HDV co‐infection, combined regimen should be administered for a longer period post‐LT. Finally, the use of grafts from hepatitis B core antibody‐positive donors is safe for HBV‐negative recipients, with the administration of lifelong antiviral prophylaxis.

Therapies against chronic hepatitis B infections: The times they are a-changin’, but the changing is slow!

“…Finally, another class of molecule is anti-HBs antibody. Immunoglobulins (HBIG; mainly targeting HBsAg) isolated from vaccinated patients have been used since many years for passive prevention of reinfection of liver grafts and mother-to-child transmission (Chen et al, 2020;Orfanidou and Papatheodoridis, 2021). Injection of these immunoglobulins in CHB patients had in contrast little value.…”

Proceedings of the 26th Annual Virtual Congress of the International Liver Transplantation Society

“…Weaning could be considered in those with long-term undetectable HBV-DNA (>5 y) or negative liver biopsies; however, more studies are required to identify eligible patients. [8][9][10] During the infectious diseases SIG meeting, Dr Degertekin, Acıbadem Healthcare Group, discussed the development of de novo HBV infection post-LT, which is seen in most cases if the donor was HBV core antibody positive. In cases wherein the recipient is not immune to HBV, posttransplant prophylaxis with oral antivirals is advised.…”

“…Weaning could be considered in those with long-term undetectable HBV-DNA (>5 y) or negative liver biopsies; however, more studies are required to identify eligible patients. 8-10…”

Role of lower dose hepatitis B immune globulin prophylaxis in liver transplantation: A single center perspective

“…[7] However, the use of HBIG has revolutionized HBV LT by decreasing HBV recurrence by 70%. [8,9] HBIG works by binding to the circulating virions and reducing HBsAg secretion during the anhepatic phase and the first postoperative week to prevent graft infection. Historically, high dose HBIG (i.e., 10 000 international unit [IU]/day) was thought to be associated with lower HBV recurrence.…”