Liver transplantation for chronic hepatitis B virus infection

Combination of hepatitis B immune globulin (HBIG) and antiviral therapy has reduced recurrent hepatitis B virus (HBV) to less than 10 percent, with resultant improvement in patient and graft survival. With the availability of new antiviral therapies that have lower rates of drug resistance and are effective against lamivudine (LAM)-resistant HBV, reinfection rate has continued to decrease. Patients with HBV-related cirrhosis who are eligible for transplantation should be started on antiviral therapy with a nucleos(t)ide analogue as soon as possible. Entecavir is preferred for patients who are nucleoside naïve or who had prior treatment with adefovir, while tenofovir is preferred for patients who had prior treatment with lamivudine or telbivudine. Entecavir or tenofovir should be continued post-transplant. Patients with undetectable HBV DNA at the time of transplant may not require HBIG post-transplant, while a short course of HBIG is warranted in patients with detectable HBV DNA at the time of transplant.The choice of treatment for recurrent hepatitis B following liver transplantation depends upon prior prophylactic therapy and presence of drug-resistant mutants. We suggest that patients who received no prophylaxis or HBIG only be treated with tenofovir or entecavir. Patients who received nucleos(t)ide analogue prophylaxis should be tested for antiviral drug resistance mutation to guide the choice of rescue therapy. In general, combination therapy is recommended, and most patients will need a combination of tenofovir with entecavir.