Prophylaxis in HBV-infected liver transplant patients: end of the HBIG era?

Improvements in the outcomes of patients transplanted for hepatitis B virus (HBV) have been substantial in the past two decades. With current therapies, the vast majority of transplant recipients are protected against recurrent and/or progressive liver disease. Effective prophylactic therapies include hepatitis B immune globulin (HBIG) plus nucleos(t)ide analogues (NAs) and NA therapy alone (without HBIG). Definitions of recurrence in the setting of prophylaxis are evolving--persistence or reappearance of hepatitis B surface antigen in serum remains a marker of reinfection, but is not necessarily a marker of progressive hepatitis. The level of HBV DNA at the time of transplant remains the most consistent factor predicting risk of recurrent HBV. An individualized, rather than a "one size fits all", approach to prophylaxis that is based on risk of reinfection and/or risk of progressive disease, if reinfected, is the optimal means of insuring optimal graft survival for HBV-infected patients.