Hepatitis B in renal transplant patients

Abstract

Hepatitis B virus (HBV) poses a significant challenge for both dialysis patients and kidney transplant recipients despite its decreasing rates, especially in developed countries. The best preventive method is vaccination. Patients with chronic renal disease should ideally be vaccinated prior to dialysis, otherwise, reinforced vaccination practices and close antibody titer monitoring should be applied while on dialysis. HBV infected dialysis patients who are renal transplant candidates must be thoroughly examined by HBV-DNA, and liver enzyme testing and by liver biopsy. When needed, one must consider treating patients with tenofovir or entecavir rather than lamivudine. Depending on the cirrhosis stage, dialysis patients are eligible transplant recipients for either a combined kidney-liver procedure in the case of decompensated cirrhosis or a lone kidney transplantation since even compensated cirrhosis after sustained viral responders is no longer considered an absolute contraindication. Nucleoside analogues have led to improved transplantation outcomes with both long-term patient and graft survival rates nearing those of HBsAg(-) recipients. Moreover, in the cases of immunized HBsAg(-) potential recipients with concurrent prophylaxis, we are enabled today to safely use renal grafts from both HBsAg(+) and HBsAg(-)/anti-HBc(+) donors. In so doing, we avoid unnecessary organ discarding. Universal prophylaxis with entecavir is recommended in HBV kidney recipients and should start perioperatively. One of the most important issues in HBV(+) kidney transplantation is the duration of antiviral prophylaxis. In the absence of robust data, it seems that prophylactic treatment may be discontinued in selected stable, low-risk recipients during maintenance immunosuppression and should be reintroduced when the immune status is altered. All immunosuppressive agents in kidney transplantation can be used in HBV(+) recipients. Immunosuppression is intimately associated with increased viral replication; thus it is important to minimize the total immunosuppression burden long term.

Keywords: Hepatitis B virus (+) donor, Hepatitis B virus (+) recipient, Renal transplantation, Viral reactivation, Immunosuppression, Nucleoside analogues, Antiviral discontinuation, Antiviral prophylaxis, Hepatitis B

Core tip: Though decreasing, hepatitis B still remains a considerable problem, especially in high-risk patient populations as kidney transplant recipients. The widespread use of new antivirals and the introduction of universal prophylaxis immediately after transplantation have changed the picture in hepatitis B virus (HBV) (+) transplantation. Long term survival rates of HBV(+) recipients are approaching those of HBV(-), altering HBV(+) kidney transplantation from a “high risk” procedure into routine practice. Furthermore, accumulating evidence confirms the safety of transplantation from HBsAg(+) donors into immunized recipients. All immunosuppressants can be used in HBV(+) transplantation and total immunosuppression must be kept at the lowest possible levels long term.