Hepatitis B and liver transplantation
Chronic Hepatitis B (CHB) infection remains a common cause for liver cirrhosis and hepatocellular carcinoma. Orthotopic liver transplantation (OLT) has been a treatment modality for CHB patients with decompensated cirrhosis and or hepatocellular carcinoma. Previously early outcomes of transplantation for CHB patients were associated with rapid recurrence of the virus and loss of the allograft. Development of hepatitis B immunoglobulin (HBIG) and its use in prophylaxis of CHB patients after liver transplantation resulted in significant improvement in patient and allograft survival. Continued use of HBIG mono-therapy however has been complicated by development of viral resistance. With the development of nucleos(t)ide (NA) inhibitors for treatment of CHB, liver transplant outcomes continued to improve. One of the most important risk factors for viral recurrence in post liver transplant setting is the HBV DNA level. Use of NAs prior to liver transplantation to reduce the viral load has been an important way to prevent recurrence of CHB in post liver transplant patients. Addition of NAs to HBIG was the standard of therapy for liver transplant patients for many years and reduced the development of viral resistance. Long-term use of HBIG however is expensive and inconvenient for patients. Development of more potent NAs, with low viral resistance, has allowed for reduction and in some cases elimination of use of HBIG in post liver transplant prophylaxis of patients with CHB.