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.