Screening and Prophylaxis to Prevent Hepatitis B Reactivation: Transplant Recipients

A multi-center evaluation of hepatitis B reactivation with and without antiviral prophylaxis after kidney transplantation

BACKGROUND

Hepatitis B virus (HBV) reactivation in hepatitis B surface antigen (HBsAg) negative and hepatitis B core antibody (anti-HBc) positive kidney transplant recipients ranges between 1.4-9.6%. Limited evidence is available regarding routine antiviral prophylaxis and identifiable risk factors for HBV reactivation in this population.

METHODS

In this multi-center retrospective study, we evaluated the prevalence of HBV reactivation in HBsAg-negative anti-HBc-positive kidney transplant recipients who did or did not receive antiviral prophylaxis. The primary outcome assessed the prevalence of HBV reactivation, defined as a positive HBV DNA by PCR of any viral load at or above the minimal detection level. The principal safety outcomes assessed 1-year graft survival, 1-year all-cause mortality, biopsy proven acute rejection (BPAR), and antibody mediated rejection (AMR).

RESULTS

One-hundred sixty-one patients met inclusion criteria and comprised of two groups, antiviral prophylaxis (n=14) and no antiviral prophylaxis (n=147). Of patients who did not receive prophylaxis only five (3.4%) experienced HBV reactivation whereas one (7.1%) patient in the prophylaxis group experienced reactivation over a median follow-up of 1103 days (p= 0.43). Furthermore, there were no differences with respect to all secondary outcomes. Statistical analysis demonstrated delayed graft function to be a significant factor associated with HBV reactivation.

CONCLUSION

These study results suggest that the prevalence of HBV reactivation in HBsAg-negative anti-HBc-positive kidney transplant recipients is low, regardless of antiviral prophylaxis. Furthermore, there were no significant graft related outcomes among those that did experience reactivation. This article is protected by copyright. All rights reserved.

Risk of disease transmission in an expanded donor population: the potential of hepatitis B virus donors

PURPOSE OF REVIEW

Lack of availability of donor organs is a constant challenge that patients and providers face in transplantation. To address this shortage, donors that test positive for hepatitis B, in particular those with resolved infection, have been increasingly utilized in clinical practice. We review here the potential risks for the recipient and the advances in hepatitis B management that have made use of these donors a well tolerated and advisable proposition.

RECENT FINDINGS

As routine administration of antiviral prophylaxis in the posttransplant setting among those deemed high risk for transmission, outcomes for recipients of hepatitis B donors, including liver transplant recipients, have been comparable to uninfected donors. Universal hepatitis B nucleic acid testing of donors has also enhanced our ability to accurately inform recipients regarding transmission risk. Appropriate use of prophylaxis and careful monitoring for transmission posttransplant is key to ensuring no adverse outcomes occur.

SUMMARY

Treatment of hepatitis B has evolved over the past two decades. Expanding the donor pool with hepatitis B donors is now well tolerated, ethical, and advantageous to the transplant community at large. A clear discussion with recipients on the substantial benefit and low harm of using hepatitis B donors will lead to greater acceptance and utilization of these organs.