Hepatitis B after transplant

Question: A 47 year old Cambodian male with HBV is transplanted today; he developed hepatocellular carcinoma and was on the waiting list for less than six months.  Going into surgery, he was on entecavir 0.5 mg daily and had a negative viral load.  What do you recommend he receives as secondary prophylaxis post-transplant?

A. entecavir monotherapy

B. HBIg monotherapy

C. entecavir + HBIg

D. no prophylaxis is needed if viral load is negative at time of surgery

Answer: With appropriate secondary prophylactic measures, hepatitis B reinfection post-transplant is rare (< 10%).  There are no cases that require zero medications, so the last answer choice should be discarded.

In the first year post-transplant hepatitis B immunoglobulin (HBIg, or “hepatitis B surface antibody”) is typically given.  The goal is to keep the surface antibody level >500 IU/L, or at some centers >100 IU/L.  By the second year, HBIg may no longer be necessary. Or, if it is, it can be given IM instead of IV.

Antiviral therapies are also a mainstay of treatment.  For patients that are treatment naive, or if they are on pre-transplant monotherapy without drug resistance, a single agent can be used (in conjuction with HBIg).  For patients with a very high pre-transplant viral load or with drug-resistant strains of HBV, two agents are often used in conjunction with HBIg.

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