Hepatitis B in transplantation

Abstract

Hepatitis B has been a major challenge within the field of transplantation over the past few decades. Due to aggressive recurrence post-transplant, patients with hepatitis B have been excluded from the benefits of both solid organ and bone marrow transplants. Progress has been made, however, through an improved understanding of the biology of hepatitis B and the development of new antiviral strategies that can reliably suppress the virus. Patients with hepatitis B are now candidates for transplantation in an increasing number of circumstances. Careful pre-transplant evaluation is mandatory, together with a tailored antiviral regimen depending on the replicative status of the virus and the organ being transplanted. Minimizing steroid dose following transplantation is an important part of the strategy to reduce the risk of viral reactivation. Lamivudine has been an important development and it has assumed an increasing role in the management of these patients. As additional antivirals are developed, increasingly effective drug combinations will prevent viral recurrence as well as the emergence of drug-resistant mutants, which plagues the use of single agents. It is a rapidly evolving field and there is every reason for continued optimism.

Occult hepatitis B in renal transplant patients

“…Furthermore it was recently suggested that the association of HBV and HCV infections would place these patients at higher risk of developing hepatocellular carcinoma, with a lower response to interferon‐α therapy and greater progression to cirrhosis (6, 23). Other reports suggest that in patients with occult HB the virus may be reactivated in its clinical or conventional laboratory form, and this is especially true in immunocompromised hosts (13, 15). It has also been suggested that HBV may have its genes activated by corticosteroid therapy and possibly other immunosuppressive agents (13).…”

“…Published data indicate distinct situations ranging from no influence in the course of liver disease to a carcinogenic role (9, 11, 12). Other suggested effects include a quicker progression to cirrhosis, less effective response to interferon‐α, and higher incidence of hepatocellular carcinoma in patients with occult HB co‐infected by HCV (6, 13–15).…”

“…Renal transplant patients are often infected by HBV and/or HCV as a result of their epidemiological exposures, either by dialysis, transfusions, or during the transplantation procedure. In this population, the course of the viral liver disease by isolated B or C viruses is controversial; however, it has been clearly established that co‐infection by HBV and HCV determines an unfavorable prognosis (1, 13, 15, 16).…”

Hepatitis B reactivation in the setting of chemotherapy and immunosuppression - prevention is better than cure

“…Forty-one percent of breast cancer patients positive for HBsAg have been reported to experience HBVr [18] . HBVr has been reported in patients receiving immunosuppression for inflammatory bowel disease [37,38] , rheumatological diseases (rheumatoid arthritis, ankylosing spondylitis) [39][40][41][42][43][44] , dermatological disorders (psoriasis) [45] , autoimmune disorders [46,47] and in those following solid organ transplantation (e.g., renal and liver) [48][49][50][51][52] .…”

Effect of perioperative steroids on renal function after liver transplantation*

“…Adverse consequences of steroids in liver transplantation include earlier recurrence of hepatitis C [3,4], impairment of wound healing [5], increased recurrence of other viruses [6], and providing an inadequate 'window of opportunity for immunological engagement' [7]. Within our own unit, postoperative corticosteroids are used restrictively and avoided where possible.…”