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World J Hepatol. Mar 18, 2016; 8(8): 385-394
Published online Mar 18, 2016. doi: 10.4254/wjh.v8.i8.385
Management of hepatitis B reactivation in immunosuppressed patients: An update on current recommendations
Fernando Bessone, Melisa Dirchwolf
Fernando Bessone, Department of Gastroenterology and Hepatology, School of Medicine, University of Rosario, Rosario 2000, Argentina
Melisa Dirchwolf, Department of Hepatology, Muñiz Hospital, Buenos Aires 1282, Argentina
Author contributions: Bessone F and Dirchwolf M contributed equally to this review article.
Conflict-of-interest statement: None of the authors have received fees for serving as a speaker or consultant, nor have they received research funding in relation to this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Fernando Bessone, MD, Full Professor of Gastroenterology, Department of Gastroenterology and Hepatology, School of Medicine, University of Rosario, Urquiza 3100, Rosario 2000, Argentina. bessonefernando@gmail.com
Telephone: +54-341-4393511 Fax: +54-341-4393511
Received: May 23, 2015
Peer-review started: May 25, 2015
First decision: August 16, 2015
Revised: January 15, 2016
Accepted: March 7, 2016
Article in press: March 9, 2016
Published online: March 18, 2016
Abstract

The proportion of hepatitis B virus (HBV) previously exposed patients who receive immunosuppressive treatment is usually very small. However, if these individuals are exposed to potent immunosuppressive compounds, the risk of HBV reactivation (HBVr) increases with the presence of hepatitis B surface antigen (HBsAg) in the serum. Chronic HBsAg carriers have a higher risk than those who have a total IgG anticore as the only marker of resolved/occult HBV disease. The loss of immune control in these patients may results in the reactivation of HBV replication within hepatocytes. Upon reconstitution of the immune system, infected hepatocytes are once again targeted and damaged by immune surveillance in an effort to clear the virus. There are different virological scenarios, and a wide spectrum of associated drugs with specific and stratified risk for the development of HBVr. Some of this agents can trigger a severe degree of hepatocellular damage, including hepatitis, acute liver failure, and even death despite employment of effective antiviral therapies. Currently, HBVr incidence seems to be increasing around the world; a fact mainly related to the incessant appearance of more powerful immunosuppressive drugs launched to the market. Moreover, there is no consensus on the length of prophylactic treatment before the patients are treated with immunosuppressive therapy, and for how long this therapy should be extended once treatment is completed. Therefore, this review article will focus on when to treat, when to monitor, what patients should receive HBV therapy, and what drugs should be selected for each scenario. Lastly, we will update the definition, risk factors, screening, and treatment recommendations based on both current and different HBV management guidelines.

Keywords: Anti-tumor necrosis factor-α drugs, Acute liver failure, Biologic therapy, Immunosuppressive therapy, Hepatitis B

Core tip: Chronic hepatitis B surface antigen carriers have a high risk to develop hepatitis B virus (HBV) reactivation (HBVr) when exposed to immunosupresive therapy. The loss of immune control in these patients may results in an increase in HBV replication. There is a wide spectrum of associated drugs with specific and stratified risk for the development of HBVr. Currently, HBVr incidence seems to increase worldwide, mainly due to the appearance of more powerful immunosuppressive drugs. This review article focus on when to treat, when to monitor, what patients should receive HBV therapy, and what drugs should be selected in each scenario. We updated here current HBV management guidelines.