Trends in the Management of Hepatitis B Virus Infection after Liver Transplantation

Abstract

SUMMARY
Post-transplant hepatitis B virus (HBV) recurrence occurs
in the majority of patients transplanted for HBV liver disease,
if left untreated. Post-transplant prophylaxis with
hepatitis B immune globulin (HBIG) has significantly
reduced HBV recurrence rates, but it is rather ineffective
in patients with chronic liver disease and pre-transplant
detectable serum HBV-DNA by hybridization assays. Moreover,
long-term HBIG administration increases the cost of
post-transplant medical therapy and may be associated with
emergence of escape HBV mutants. Lamivudine is the first
antiviral agent to be widely used in the management of HBV
transplant patients. Pre-transplant lamivudine therapy
lowers HBV viremia, decreasing the risk of post-transplant
HBV recurrence, but to try and minimize virologic breakthroughs
due to resistant HBV strains, it should be started
within the prior to 6 months the anticipated timing of transplantation,
which is often difficult in practice. Prophylactic
post-transplant lamivudine monotherapy is associated
with progressively increasing HBV recurrence rates, but
combined therapy with lamivudine and HBIG at relatively
low dosage is currently the most effective approach in this
setting, even in HBV-DNA positive patients, who also receive
lamivudine in the pre-transplant period. The most frequent
therapy for post-transplant HBV recurrence is lami- vudine, but the increasing resistance rates represent a challenging
problem. Adefovir dipivoxil is currently the most
promising agent amongst those tried for lamivudine resistant
HBV strains. All these advances in anti-HBV therapy
have made HBV liver disease an indication for liver transplantation,
irrespective of viral replication status, a complete
turn around from 10 years ago.
Key words: hepatitis B virus, liver transplantation, hepatitis
B immune globulin, nucleoside analogues, lamivudine, adefovir,
entecavir, viral resistance, YMDD mutants