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Evaluation of Italian clinical practice for preventing HBV recurrence post-LT: a Delphi panel study
Sara Battistella1, Federico LE Piane2, Antonio Galante3
1Unit of Gastroenterology, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy.
Background:
The combination of hepatitis B immunoglobulin (HBIG) and high-barrier nucleos(t)ide analogues (hbNUCs) is widely considered the standard of care for preventing hepatitis B virus (HBV) recurrence after liver transplantation (LT). However, clinical practices in Italy remains heterogenous, particularly regarding HBIG dosage, administration intervals, formulation choice, and selection of patients eligible for hbNUCs monotherapy or short-course HBIG regimens. This modified Delphi panel aimed to characterize current Italian practices for HBV prophylaxis after LT, focusing on patient risk stratification and HBIG management.
Methods:
Sixteen Italian experts from EPAteam network participated in the three-round modified Delphi panel. After defining key clinical questions, a 35-item online survey was conducted. Any item with <66% agreement was designed as "controversial." Survey results and controversial topics were reviewed in a final in-person consensus meeting.
Results:
All the sixteen panelists completed each Delphi round. There was agreement that the combination of hbNUCs and HBIG constitutes the standard HBV prophylaxis after LT. Patients with HBV-DNA >20,000IU/mL at LT and those with hepatitis D virus (HDV) coinfection were identified as high-risk for HBV recurrence and deemed candidates for life-long HBIG. No consensus was achieved on the optimal duration of prophylaxis for low-risk patients, nor on specific HBIG dosage and administration intervals for either risk group. Subcutaneous formulation was preferred for older patients without caregivers, frequent travelers, and those with coagulopathy.
Conclusions:
This modified Delphi panel confirmed that life-long combination of HBIG and NUCs remains the gold standard for the HBV prophylaxis after LT. Significant variability persists in clinical practice. Prophylactic strategies, especially in low-risk patients, are largely determined on a case-by-case basis, guided by patient characteristics rather than standardized protocols.
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