Limited hepatitis B immune globulin following liver transplant for hepatitis B
Introduction
The standard of care at many institutions for prevention of hepatitis B virus (HBV)
recurrence after liver transplant (LTx) is indefinite hepatitis B immune globulin (HBIg)
therapy in combination with an oral nucleos(t)ide inhibitor. This regimen, which is both
expensive and time consuming, results in HBV recurrence rates of 5%. Long-term data
regarding the efficacy of other prophylactic options is lacking. The goal of this study was
to examine the long-term outcomes in LTx patients with HBV who were treated with
nucleos(t)ide inhibitors and no HBIg maintenance. Our hypothesis is that oral
nucleos(t)ide inhibitors, in the absence of HBIg, can yield equal or greater efficacy than
HBIg in preventing recurrent hepatitis B after LTx for hepatitis B.
Methods and Results
Charts of patients who received LTx at our institution for HBV-related liver complications
(cirrhosis, HCC, acute liver failure) were reviewed and analyzed retrospectively. There
were 45 patients included in this study who received limited HBIg prophylaxis and were
maintained on nucleos(t)ide inhibitors long-term. Mean follow up time was 4.8 years
post-transplant (range 0.2 to 11 years), during which three patients (6.7%) developed
recurrence of HBV, which was defined by presence of HBV DNA or positive hepatitis B
surface antigen (HBsAg). Two of those patients became HBsAg positive while remaining
HBV DNA negative. The third patient with recurrence became HBV DNA positive while
remaining HBsAg negative and was found to be non-compliant with medication and
became HBV DNA negative again once tenofovir was resumed.
Discussion
Our HBV recurrence rate at the end of the study was 6.7%. However, one instance of
recurrence in our study was related to medication non-compliance. Once this patient
resumed tenofovir, the HBV DNA level became undetectable and has remained
negative, now 9.4 years post LTx. The clinical impact of HBV recurrence in our study
seems to be minimal. Two of the three patients with recurrence have maintained
excellent liver function after a mean 6 years follow up since recurrence. Only one patient
with HBsAg positivity required retransplantation due to biliary strictures, not HBV
recurrence. This patient’s course can be explained by the well-known complication of
biliary strictures that occurs in deceased donor LTx.
Conclusion
Indefinite HBIg therapy adds significant expense to the prevention of HBV post-LTx. Our
regimen of nucleo(t)side inhibitors with only limited HBIg is an efficacious and cost
effective means to prevent recurrence of post-liver transplant HBV.