Review of the pharmacological management of hepatitis B viral infection before and after liver transplantation

Abstract

The progress in treatment against hepatitis B virus (HBV) with the development of effective and well tolerated nucleotide analogues (NAs) has improved the outcome of patients with HBV decompensated cirrhosis and has prevented post-transplant HBV recurrence. This review summarizes updated issues related to the management of patients with HBV infection before and after liver transplantation (LT). A literature search using the PubMed/Medline databases and consensus documents was performed. Pre-transplant therapy has been initially based on lamivudine, but entecavir and tenofovir represent the currently recommended first-line NAs for the treatment of patients with HBV decompensated cirrhosis. After LT, the combination of HBV immunoglobulin (HBIG) and NA is considered as the standard of care for prophylaxis against HBV recurrence. The combination of HBIG and lamivudine is related to higher rates of HBV recurrence, compared to the HBIG and entecavir or tenofovir combination. In HBIG-free prophylactic regimens, entecavir and tenofovir should be the first-line options. The choice of treatment for HBV recurrence depends on prior prophylactic therapy, but entecavir and tenofovir seem to be the most attractive options. Finally, liver grafts from hepatitis B core antibody (anti-HBc) positive donors can be safely used in hepatitis B surface antigen negative, preferentially anti-HBc/anti-hepatitis B surface antibody positive recipients.

Keywords: Adefovir; Antivirals; Entecavir; Hepatitis B virus; Hepatitis B virus immunoglobulin; Lamivudine; Liver transplantation; Resistance; Telbivudine; Tenofovir.

Figure 1

Risk of recurrence of hepatitis B virus infection after liver transplantation in relation to the type of post-transplant hepatitis B virus prophylaxis[64]. HBIG: Hepatitis B immunoglobulin; LAM: Lamivudine; ETV: Entecavir; TDF: Tenofovir; LT: Liver transplantation.

Figure 2

Proposed algorithm for allocation and management of anti-hepatitis B core positive liver grafts. Such grafts should be first offered to hepatitis B surface antigen positive, then to anti-hepatitis B core (HBc) and/or anti-hepatitis B surface (HBs) positive and lastly to hepatitis B virus naive (both anti-HBc and anti-HBs negative) recipients[79]. LT: Liver transplantation; HBIG: Hepatitis B immunoglobulin; LAM: Lamivudine.