Monotherapy versus combination therapy in the prevention of hepatitis B in liver transplant recipients

Tremendous progress with liver transplantation for hepatitis B-related liver disease has occurred over the past decade, primarily through advances in antiviral therapy. In the most recent clinical trials, reinfection of the transplanted allograft with host hepatitis B virus has been shown to be rare, even in patients with evidence of viral replication at the time of liver transplantation. The elimination of recurrent infection has allowed centres to investigate more cost-effective protocols. However, additional research, both clinical and basic, is needed to prevent the emergence of drug-resistant infections. This article compares the current protocols for the prevention of recurrent infection with reference to the worldwide experience of liver transplantation for hepatitis B over the last 30 years. Nonviraemic patients (positive for hepatitis B surface antigen only) can receive a liver transplant with a low risk of recurrent infection using lamivudine alone, hepatitis B immunoglobulin (HBIG) alone or HBIG and lamivudine in combination. Viraemic patients (positive for either hepatitis B e antigen or viral DNA) should receive treatment exclusively with HBIG plus lamivudine. A pretransplant course of lamivudine may not be necessary in either group of patients, and it poses the additional risk of the emergence of a YMDD mutant infection prior to transplantation.