Management of hepatitis B in special populations

Abstract

Special populations infected with chronic HBV include those with decompensated cirrhosis, coinfections (HIV, HCV, HDV), hemodialysis and renal failure, immunosuppressed including transplant patients, children and women in pregnancy. These populations differ in their natural history and risk for liver-related complications, the indications for anti-HBV therapy as well as the recommendations regarding the HBV drugs used, duration of therapy and anticipated endpoints. Reflecting the special populations with substantive changes in management in recent years, this review focuses on HBV-HIV coinfected patients, immunosuppressed patients at risk for reactivation, liver transplant recipients and pregnant women. Management of women in the context of pregnancy and post-partum requires consideration of risks to mother and fetus/infant, including the risk of mother-to-child transmission. HBV-HIV coinfected patients require initiation of treatment concurrent with their HIV therapy and the HBV drugs used must by selected to minimize HIV and HBV resistance long-term. Increasing recognition of the risk for HBV reactivation with immunosuppressive therapy has led to recommendations to use prophylactic HBV therapy in patients with moderate to high risk of reactivation. Liver transplant recipients with HBV require life-long therapy to prevent or treat HBV infection but with current therapies, graft and patient survival are excellent.

Keywords: Entecavir; HBV–HIV coinfection; Nucleos(t)ide analogues; Pregnancy; Reactivation; Tenofovir; Transplantation.

Fig. 1.. Management algorithm of chronic HBV infection during pregnancy.

Initial assessment requires a determination of the need for treatment of chronic HBV, independent of pregnancy. This will determine the need for treatment during pregnancy and after delivery. For women without active or advanced chronic HBV infection, antiviral therapy can be deferred until post-partum. However, all women need to be assessed in the second trimester for consideration of antiviral therapy for prevention of mother-to-child transmission. Women with HBV DNA above 200,000 IU/mL warrant antiviral therapy with tenofovir, telbivudine or lamivudine in the third trimester. Tenofovir is the preferred drug during pregnancy.

Fig. 2.. Factors to consider for individualization of HBV prophylaxis in liver transplant recipients.

Prophylaxis can be individualized with patients at low risk for recurrent HBV treated without HBIG or with short duration HBIG. Other important factors to consider include HBIG availability and cost, presence of coinfections (HDV and HIV) and adherence.* Short term HBIG varies from 5 days to 6 months.