Prevention of Hepatitis B Virus Reinfection in Liver Transplant Recipients

Abstract

Antiviral therapy using newer nucleos(t)ide analogues with lower resistance rates such as entecavir or tenofovir could suppress hepatitis B virus (HBV) replication, improve liver function, delay or obviate the need for liver transplantation in some patients, and reduce the risk of HBV recurrence. The combination of long-term antiviral and low-dose hepatitis B immune globulin (HBIG) can effectively prevent HBV recurrence in more than 90% of transplant recipients. Some form of HBV prophylaxis needs be continued indefinitely after transplantation. However, in patients with a low risk of HBV recurrence (i.e. HBV DNA levels undetectable before transplantation), it is possible to discontinue HBIG and maintain long-term antiviral therapy. A more cautious approach to prophylaxis regimen is necessary for those patients with high pretransplant HBV DNA levels, those with limited antiviral options if HBV recurrence occurs (i.e. HIV or HDV coinfection, preexisting drug resistance), those with a high risk of hepatocellular carcinoma recurrence, and those with a risk of noncompliance to antiviral therapy.

Role of nucleoside/nucleotide analogues and low-dose hepatitis B immune globulin in prophylaxis of hepatitis B recurrence among cadaveric liver transplant recipients

“…High-risk patients such as those with HCC at LT, significant risk or history of nonadherence to AV therapy, high HBV DNA titers pre-transplant, and limited AV options in case of HBV recurrence (HIV or HDV coinfection, pre-existing intolerance, or drug resistance) should not be started on HBIG-free regimen. If HBIG is given, it should be done with caution and on case-by-case basis (31). The standard of care based on the American Association for the Study of Liver (AASLD) and Asia Pacific Association for the Study of Liver guidelines on the prevention of recurrent HBV post-LT recommend that in low-risk patients, who have undetectable HBV DNA levels at the time of transplant, high-potency AVs alone can be used indefinitely.…”

The detection of (total and ccc) HBV DNA in liver transplant recipients with hepatitis B vaccine against HBV reinfection

“…The combination prophylaxis with antiviral agents and HBIG reduces the HBV recurrence rate to 5% at 5 years, which is now almost universally adopted by most transplant centers as the golden standard for the prevention of HBV reinfection. 4 However, passive immune prophylaxis with long-term administration of HBIG is associated with many issues, including the limited availability of HBIG, possible emergence of HBV envelope protein mutations, 5 development of resistance to nucleotide analogs 6 and, especially, extremely high costs. 7 The ideal prophylactic strategy is to stop prophylaxis with HBIG when HBV infection had been completely cleared.…”

Management of special patient groups with hepatitis B virus infection: The EASL 2017 Clinical Practice Guidelines

“…Post-transplant HBV recurrence may lead to graft loss and mortality as a result of HBVinduced aggressive hepatitis (5)(6)(7). Treatment with a combination of nucleos(t)ide analogs (NAs) and hepatitis B immunoglobulin (HBIG) has dramatically decreased HBV recurrence and improved the clinical outcome after LT (5)(6)(7)(8)(9)(10).…”

“…Treatment with a combination of nucleos(t)ide analogs (NAs) and hepatitis B immunoglobulin (HBIG) has dramatically decreased HBV recurrence and improved the clinical outcome after LT (5)(6)(7)(8)(9)(10). Entecavir (ETV) or tenofovir disoproxil fumarate (TDF) and HBIG combination therapy decrease the risk of graft infection to <5% (1,8).…”