Evolution of hepatitis B management in kidney transplantation

Abstract

Chronic hepatitis B virus (HBV) infection adversely influences the clinical outcomes of renal transplant recipients owing to increased hepatic complications. Management of HBV infection in kidney transplant recipients presents a challenge to clinicians, especially in endemic regions. Interferon precipitates renal allograft dysfunction. Treatment with lamivudine, the first oral nucleoside analogue available, resulted in effective viral suppression, reduced liver-related complications, and improved patient survival so that medium-term data showed comparable patient survival rates between hepatitis B surface antigen-positive and HBsAg-negative kidney transplant recipients in the era of effective antiviral therapies. Entecavir has replaced lamivudine as first-line therapy for treatment-naïve subjects in view of the propensity for drug resistance with the latter. Management of HBV infection in kidney transplant patients needs to take into consideration the nephrotoxicity of nucleoside/tide analogues such as adefovir and tenofovir. Prevention of HBV-related complications in kidney transplant recipients starts much earlier prior to transplantation, with vaccination of patients with chronic kidney disease and donor-recipient matching with regard to HBV status. In addition to anti-viral treatment, patients with chronic HBV infection must have regular surveillance for liver cancer and assessment for the development of cirrhosis.

Keywords: Hepatitis B; Kidney transplantation

Core tip: Treatment with oral nucleoside/tide analogues brought a new paradigm in the management of hepatitis B surface antigen-positive kidney transplant recipients, resulting in effective viral suppression, reduced hepatic complications, and improved patient survival, without compromising renal allograft outcome. Entecavir has replaced lamivudine as first-line therapy for treatment-naïve subjects given the propensity of lamivudine for selecting resistance. Due to the nephrotoxicity of adefovir and tenofovir, the optimal management of drug-resistant hepatitis B virus (HBV) remains to be defined. Other important measures to prevent HBV-related complications in renal transplant patients include early vaccination in non-immune subjects, donor-recipient matching of HBV status, and surveillance for liver cancer and cirrhosis.