Published online Jan 7, 2016. doi: 10.3748/wjg.v22.i1.165
Peer-review started: May 20, 2015
First decision: August 26, 2015
Revised: November 11, 2015
Accepted: December 14, 2015
Article in press: December 14, 2015
Published online: January 7, 2016
Liver transplantation (LT) is a considerably effective treatment for patients with end-stage hepatitis B virus (HBV)-related liver disease. However, HBV infection often recurs after LT without prophylaxis. Since the 1990s, the treatment for preventing HBV reinfection after LT has greatly progressed with the introduction of hepatitis B immunoglobulin (HBIG) and nucleos(t)ide analogues (NAs), resulting in improved patient survival. The combination therapy consisting of high-dose HBIG and lamivudine is highly efficacious for preventing the recurrence of HBV infection after LT and became the standard prophylaxis for HBV recurrence. However, mainly due to the high cost of HBIG treatment, an alternative protocol for reducing the dose and duration of HBIG has been evaluated. Currently, combination therapy using low-dose HBIG and NAs is considered as the most efficacious and cost-effective prophylaxis for post-LT HBV reinfection. Recently, NA monotherapy and withdrawal of HBIG from combination therapy, along with the development of new, potent high genetic barrier NAs, have provided promising efficacy, especially for low-risk recipients. This review summarizes the prophylactic protocol and their efficacy including prophylaxis of de novo HBV infection from anti-HBc antibody-positive donors. In addition, challenging approaches such as discontinuation of all prophylaxis and active immunity through hepatitis B vaccination are discussed.
Core tip: Combination therapy consisting of high-dose hepatitis B immunoglobulin (HBIG) and lamivudine has been the standard prophylaxis for hepatitis B virus recurrence after liver transplantation. Currently, after development of more potent high genetic barrier nucleos(t)ide analogues (hgbNAs), such as entecavir and tenofovir disoproxil fumarate, combination therapy using low-dose HBIG and hgbNA is considered as the most efficacious and cost-effective prophylaxis. In addition, monotherapy with hgbNAs and withdrawal of HBIG following combination therapy of HBIG and hgbNAs could be promising approaches, especially for low-risk patients and those receiving grafts from hepatitis B core antibody-positive donors. This review discusses those approaches including other challenging therapeutic options.