Short course of HBIG plus long-term antivirals may prevent HBV reinfection after transplant

Last Updated: 2017-05-19

By Will Boggs MD

NEW YORK (Reuters Health) - A very short course of hepatitis B immunoglobulin (HBIG) after liver transplantation, along with long-term antiviral therapy, may prevent hepatitis B virus (HBV) reinfection, a retrospective study suggests.

"We believe our approach of providing HBIG in the immediate/early transplant period is important to protect the new liver from infection,” said Dr. Norah A. Terrault from the University of California, San Francisco.

“This is in contrast to use of antivirals alone (as championed by the Hong Kong group with excellent results), which may prevent disease (by suppressing virus that reinfects the new liver) but may not prevent reinfection,” she told Reuters Health by email. “Both approaches are associated with high efficacy, but prevention of reinfection may offer the opportunity in future to discontinue prophylaxis.”

Combining antiviral drugs and HBIG is the mainstay of HBV prophylaxis, but there is no consensus regarding the duration of use and dose of HBIG as a component of such prophylaxis.

Dr. Terrault's team at UCSF modified their HBV prophylaxis protocol to a five-day course of HBIG combined with long-term antiviral therapy in HBV monoinfected patients with low viremia levels before transplantation.

Patients received HBIG 5000 IU intravenously in the anhepatic phase of liver transplantation and then daily for five days postoperatively (six doses total) and received antiviral therapy indefinitely.

The 42 patients included in the report, online April 18 in Transplantation, were followed a median 3.1 years after liver transplantation; the cumulative incidence of hepatitis B surface antigen (HBsAg) recurrence was 2.9% at one, three, and five years post-liver transplantation.

Only one patient became HBV DNA positive, and that patient had recurrent hepatocellular carcinoma.

Two patients died during follow-up, one from metastatic hepatoma and one from infection and multiorgan failure.

“This is a simple and highly effective prophylactic regimen - just 5 days of HBIG with long-term antivirals - that we feel transplant programs can adopt,” Dr. Terrault said. “Currently, many programs give longer duration HBIG (which increases total cost of prophylaxis).”

“Additionally, we found that the only patients who showed evidence of HBV post-transplant (N=2) were those who had recurrence of liver cancer,” she said. “This has been shown by others, but suggests that rather than the new liver being infected, the HBV detected is the liver cancer.”

Dr. James Y. Y. Fung from the University of Hong Kong, who recently reported on the effectiveness of entecavir monotherapy for preventing HBV reactivation after liver transplantation, told Reuters Health by email, "In fact, the paradigm for antiviral therapy after liver transplantation for chronic hepatitis B has gradually shifted from long-time high-dose HBIG, to low-dose HBIG, to shortened-duration HBIG, and even HBIG-free completely. Long-term data from Hong Kong has demonstrated that oral antiviral alone without HBIG can prevent recurrent graft hepatitis with excellent long-term survival.”

“Limited-duration HBIG and long-term antiviral therapy is highly effective and is associated with good long-term survival, especially for those with low or non-detectable viral load at the time of transplant,” he concluded. “As antiviral therapy is widely available these days, most patients, apart from those with severe acute flares, will fall into this category.”

SOURCE: http://bit.ly/2rylOFW

Transplantation 2017.