From the Guidelines
For a hepatitis B core antibody positive donor lung transplanted into a hepatitis B vaccinated recipient, the recommended management includes prophylactic antiviral therapy with entecavir 0.5 mg daily or tenofovir 300 mg daily, starting immediately post-transplant and continuing for at least 6-12 months, as supported by the most recent guidelines 1. The management approach for such patients involves several key considerations:
- Prophylactic antiviral therapy is crucial to prevent viral reactivation in the immunosuppressed transplant recipient, despite their vaccination status, as the immunosuppressive medications can suppress the recipient's vaccine-induced immunity 1.
- Regular monitoring of hepatitis B viral load (HBV DNA) should be performed monthly for the first 3 months, then every 3 months thereafter, to assess the effectiveness of antiviral therapy and detect any potential reactivation early 1.
- Liver function tests should be checked weekly for the first month, then monthly for 6 months, to monitor for any signs of liver damage or dysfunction 1.
- The recipient's hepatitis B surface antibody (anti-HBs) levels should be maintained above 100 IU/L; if levels fall below this threshold, hepatitis B immunoglobulin (HBIG) administration may be necessary to provide additional protection against viral reactivation 1. Some key points to consider in the management of these patients include:
- The risk of viral reactivation is higher in recipients with lower anti-HBs levels, emphasizing the importance of maintaining adequate antibody levels 1.
- The duration of prophylaxis may need to be extended based on immunosuppression levels and ongoing risk assessment, with some centers recommending lifelong therapy 1.
- Close monitoring and regular follow-up are essential to ensure the recipient's safety and adjust the management plan as needed 1.
From the Research
Hepatitis B Core Positive Donor Lungs Transplanted in Hepatitis B Vaccinated Patient
- The use of organs from donors previously exposed to hepatitis B virus (HBV) can pose a risk of HBV transmission to the recipient 2, 3.
- In liver transplantation, the presence of antibody against hepatitis B core antigen (HBcAb) in the donor is a marker for risk of HBV transmission and reactivation 2.
- For recipients of HBcAb-positive lungs, the risk of HBV reactivation is lower if the recipient is hepatitis B vaccinated and has a positive antibody to hepatitis B surface antigen (HBsAb) 2, 4.
- Prophylactic treatment with lamivudine or a combination of hepatitis B immunoglobulin (HBIg) and lamivudine may be considered for high-risk recipients of HBcAb-positive lungs 2, 5.
- For low-risk recipients, no prophylaxis with close serological and virological monitoring may be an alternative to lamivudine monoprophylaxis 2.
- The use of grafts from hepatitis B core antibody-positive donors is considered safe for HBV-negative recipients with the administration of lifelong antiviral prophylaxis 5, 6.
Plan of Management
- Recipients of HBcAb-positive lungs should be closely monitored for HBV reactivation and receive prophylactic treatment as needed 2, 5.
- Vaccinated recipients with a protective hepatitis B surface antibody should have surveillance serologies performed to monitor for seroconversion 4.
- Antiviral therapy, such as lamivudine or tenofovir, may be used to prevent HBV recurrence in recipients of HBcAb-positive lungs 5, 6.
- In cases of de novo HBV infection, treatment with adefovir or tenofovir may be employed to salvage the graft and obtain serum HBV DNA clearance 6.