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

Tremendous progress with liver transplantation for hepatitis B-related live r disease has occurred over the past decade, primarily through advances in antiviral therapy. In the most recent clinical trials, reinfection of the t ransplanted 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-resis tant infections. This article compares the current protocols for the prevention of recurrent infection with reference to the worldwide experience of liver transplantat ion 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 immuno globulin (HBIG) alone or HBIG and lamivudine in combination. Viraemic patie nts (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 tr ansplantation.