Ann Transplant 2009; 14(1): 17-17
The availability of prophylactic protocols including hepatitis B immunoglobulin (HBIg) and nucleos (t) ide analogue (NUC) had signifi cantly reduced a risk of recurrent hepatitis B virus infection after liver transplantation and improved survival in patients with HBV-related end stage liver disease. Also politics to transplant organ to the immune recipient with a high anti-HBs titer had markedly reduced risk of de novo HBV infection as well as pre-emptive administration of a NUC to the anti-HBc-positive recipient usually prevents from reactivation of occult HBV infection. However, HBV infection still occurs either as recurrent hepatitis B due to the unsuccessful prophylaxis or as de novo nosocomial infection, but most frequently because of use of an organ from anti-HBc positive/HBsAg-negative donor. Currently, organs from HBsAg-positive donors cannot be accepted. Livers from anti-HBc-positive donors can only be transplanted to the HBsAg-positive recipients or to the anti-HBc-positive recipients with high anti-HBs titers. The same applies to the kidney donors and recipients. Anti-HBc-positive heart and lung donors do not pose a significant risk of HBV transmission. If anti-HBc-positive livers and kidneys are transplanted into patients without immunity, prophylaxis is mandatory. In case of liver transplantation prophylactic regimen includes HBIg and lamivudine, and in kidney recipient monotherapy with lamivudine is most often chosen. However, the optimal regimen is not yet determined . In case of recurrent B hepatitis or de novo HBV infection organ recipients have to be treated promptly with one of the potent NUCs, preferably the one with high genetic barrier to resistance, i.e. entecavir (or tenofovir - still off-label). Adefovir should not be chosen in kidney recipients as there are reports of worsening of renal graft function. Antiviral therapy requires lifelong continuation of treatment. HBV-DNA levels and aminotransferase activity should be monitored every 12 to 24 weeks to seek for primary non-response, partial virological response and virological breakthrough. In primary and partial non-response a rapid switch to another NUC is recommended. In case of virological breakthrough (usually due to resistance) adding-on a second drug is the optimal strategy. Knowledge of cross-resistance to avoid multidrug resistance is obligatory .