Liver transplantation in bearers of hepatitis B associated or not with delta hepatitis in the age of the new antiviral drugs: is hyperimmune globulin still necessary?

The Management of Hepatitis B in Liver Transplant Recipients

Liver transplant (LT) is now an established indication for patients with chronic hepatitis B, mainly because of the development and use of hepatitis B immunoglobulin (HBIG) and oral antivirals for prophylaxis. The combination of low-dose HBIG and antivirals has been considered the standard prophylaxis regimen to prevent post-LT recurrence of hepatitis B. The important remaining issues are related to the long-term cost of HBIG and the risk of escape hepatitis B virus (HBV) mutants. Strategies for prevention of HBV after LT are constantly improving. With the availability of new nucleoside/nucleotide analogues, new post-LT strategies also should emerge.

Management of hepatitis B virus infection after liver transplantation

Chronic hepatitis B virus (HBV) infection is responsible for up to 30% of cases of liver cirrhosis and up to 53% of cases of hepatocellular carcinoma. Liver transplantation (LT) is the best therapeutic option for patients with end-stage liver failure caused by HBV. The success of transplantation, though, depends on receiving prophylactic treatment against post-transplant viral reactivation. In the absence of prophylaxis, liver transplantation due to chronic hepatitis B (CHB) is associated with high rates of viral recurrence and poor survival. The introduction of treatment with hepatitis B immunoglobulins (HBIG) during the 1990s and later the incorporation of oral antiviral drugs have improved the prognosis of these patients. Thus, LT for CHB is now a universally accepted option, with an estimated 5 years survival of around 85% vs the 45% survival seen prior to the introduction of HBIG. The combination of lamivudine plus HBIG has for many years been the most widely used prophylactic regimen. However, with the appearance of new more potent oral antiviral agents associated with less resistance (e.g., entecavir and tenofovir) for the treatment of CHB, new prophylactic strategies are being designed, either in combination with HBIG or alone as a monotherapy. These advances have allowed for more personalized prophylaxis based on the individual risk profile of a given patient. In addition, the small pool of donors has required the use of anti-HBc-positive donors (with the resulting possibility of transmitting HBV from these organs), which has been made possible by suitable prophylactic regimens.

Liver transplantation in a patient with hepatitis B, C and D coinfection associated with hepatocellular carcinoma: a management strategy for a rare condition. Case report

CONTEXT

Orthotopic liver transplantation (OLT) is the treatment of choice for end-stage liver disease. Cirrhosis due to hepatitis C infection is the leading indication for liver transplantation worldwide. However, patients who are given transplants because of viral liver diseases often present clinical coinfections, including hepatitis B together with hepatitis D. Currently, different strategies exist for patient management before and after liver transplantation, and these are based on different protocols developed by the specialized transplantation centers.

CASE REPORT

We present a rare case of a 58-year-old man with chronic hepatitis B, C and D coinfection. The patient developed cirrhosis and hepatocellular carcinoma. His treatment comprised antiviral therapy for the three viruses and OLT. The patient's outcome was satisfactory.

CONCLUSION

OLT, in association with antiviral therapy using entecavir, which was administered before and after transplantation, was effective for sustained clearance of the hepatitis B and D viruses. A recurrence of hepatitis C infection after transplantation responded successfully to standard treatment comprising peginterferon alfa-2A and ribavirin.

Abnormal functional connectivity within the default mode network in patients with HBV-related cirrhosis without hepatic encephalopathy revealed by resting-state functional MRI

By means of "task free" resting-state functional magnetic resonance imaging (rs-fMRI), abnormal functional connectivity (FC) of the default mode network (DMN) in cirrhotic patients with hepatic encephalopathy (HE) has been reported; however, little is known about the changes of DMN in cirrhotic patients without overt or minimal HE. The aim of this study was to investigate whether there was a disruption of the FC within the DMN in patients with hepatitis B virus (HBV)-related cirrhosis without any signs of HE. Fifty one patients with HBV-related cirrhosis without HE and 61 age- and gender-matched healthy controls underwent the rs-fMRI. Seed-based region-to-region FC was used to analyze the connectivity between each pair of regions within the DMN, including posterior cingulate cortex (PCC), medial prefrontal cortex (mPFC), hippocampal formation (HF), inferior parietal cortex (IPC), and medial temporal lobe (MTL). Pearson correlation analysis was performed between the abnormal FC strength within the DMN and venous blood ammonia levels in patients. Compared with the controls, patients with HBV-related cirrhosis without HE demonstrated significantly decreased region-to-region FC between the mPFC and bilateral MTL, right HF, and left IPC, as well as between the right MTL and left IPC, right HF, and PCC. A significant negative relationship was observed between blood ammonia levels and connectivity strength between the mPFC and left IPC in patients. These results suggest that patients with HBV-related cirrhosis without HE had disrupted functional connectivty within the DMN, even before the appearance of minimal HE.

Hepatitis B immune globulin in liver transplantation prophylaxis: an update

CONTEXT

Liver transplantation is the best treatment option for end-stage liver disease following hepatitis B (HBV) infection. However, the high rate of recurrence of HBV infection following transplantation is a disadvantage of this option.

EVIDENCE ACQUISITION

Over the past 2 decades, the gold standard of prophylactic treatment for the prevention of HBV re-infection following liver transplantation has been the administration of low- to high-dose hepatitis B immune globulin (HBIg) along with an antiviral agent to induce passive immunity.

RESULTS

The effectiveness of HBIg in preventing the recurrence of HBV depends on the dosage, route of administration, and duration of HBIg treatment, and the viremic status at the time of transplantation. There is currently no consensus on a standardized recommendation for therapeutic options that include HBIg administration.

CONCLUSION

This review attempts to summarize the available data on the feasibility of such options. Most recent studies support the use of long-term combination therapy of HBIg and antiviral NAs (especially new agents).