Treatment of recurrence of hepatitis B in transplant patients

Tenofovir-emtricitabine therapy for the prevention of hepatitis B recurrence in four patients after liver transplantation

In patients infected with chronic hepatitis B virus (HBV) that goes untreated, therapeutic options are limited once the disease decompensates, and orthotopic liver transplantation is often the only treatment available to save the patient's life. After liver transplantation, combined therapy with hepatitis B immune globulin (HBIG) and a nucleos(t)ide analog is the standard of practice for the prevention of HBV recurrence. Historically, nucleos(t)ide analogs such as lamivudine and adefovir have been used with low-dose HBIG for the prevention of HBV recurrence after liver transplantation. However, these analogs are ineffective when used alone due the emergence of resistance mutations. Newer nucleos(t)ide analogs such as tenofovir disoproxil fumarate have demonstrated higher resistance thresholds and effective viral suppression when paired with low-dose HBIG. In this case series, we evaluated the safety and efficacy of switching four patients from low-dose HBIG plus nucleos(t)ide analog therapy for the prevention of HBV recurrence to a combination tenofovir-emtricitabine regimen. At the end of follow-up, all patients remained hepatitis B surface antigen negative and had HBV DNA levels of less than 10 IU/ml. Additionally, no tenofovir-associated nephrotoxicity was observed among the four patients. Tenofovir-emtricitabine monotherapy in lieu of HBIG plus nucleos(t)ide analog therapy demonstrated prevention of HBV recurrence without tenofovir-associated nephrotoxicity after 9 months of follow-up in all four patients and up to 15 months in one patient.

Role of combination therapy in chronic hepatitis B

Combination therapy includes the use of two or more antivirals for the treatment of chronic hepatitis B. No study has shown that combination therapy is superior to monotherapy in naive patients for achieving treatment end points, but combination appears to result in a lower incidence of resistance. Moreover, the higher-potency compounds have not yet been studied. Consideration should be given to treating lamivudine-resistant patients with combination therapy, preferably with a nucleotide analogue in conjunction with a nucleoside analogue. Combination therapy should be considered in patients with decompensated cirrhosis who are unable to achieve an undetectable viral level on monotherapy and in naive patients who still have a detectable viral level 6 to 12 months after starting therapy.

Viral hepatitis after liver transplantation

Recurrence of the original liver disease following liver transplantation is a typical complication in viral hepatitis. Recent advances, particularly the development of strategies to prevent or effectively treat hepatitis B, have led to substantial improvements in the post-transplantation outcome of hepatitis B candidates. While the efficacy of antivirals to treatrecurrent hepatitis C has improved in recent years, there is as yet no therapy to universally prevent recurrent infection, and tolerability of antivirals remains a matter of concern.

Recurrence of diseases following orthotopic liver transplantation

Long-term graft survival and mortality after liver transplantation continue to improve. However, disease recurrence remains a major stumbling block, especially among patients with hepatitis C. Chronic hepatitis C recurs to varying degrees in nearly all patients who undergo transplantation. Transplantation for hepatitis C is associated with higher rates of graft failure and death compared with transplantation for other indications, and retransplantation for hepatitis C related liver failure remains controversial. Recurrence of hepatitis B has been markedly reduced with improved prophylactic regimens. Further, rates of hepatocellular carcinoma recurrence have also decreased, as improved patient selection criteria have prioritized transplantation for those with a low risk of recurrence. Primary biliary cirrhosis recurs in some patients, but it is often relatively mild. Autoimmune liver disease has also been shown to have a relatively benign post-transplantation course, but some studies have indicated that it slowly progresses in most recipients. It has been recently reported that alcoholic liver disease liver transplant recipients who return to drinking have worsened mortality. In such patients worse outcomes are not due to graft failure, but instead to other comorbidities. Recurrences of other diseases, including nonalcoholic steatohepatitis and primary sclerosing cholangitis, are now being recognized as having potentially detrimental effects on graft survival and mortality. Expert clinical management may help prevent and treat complications associated with disease recurrence.