Dual therapy with nucleos(t)ide analogues in the prevention of hepatitis B virus recurrence after liver transplantation: Two case reports

Abstract

BACKGROUND

Infection by the hepatitis B virus (HBV) represents a significant global socio-sanitary burden. While liver transplantation (LT) is an important therapeutic option, treatments that prevent HBV reinfection are necessary. The combination of anti-hepatitis B immunoglobulin (HBIG) and nucleoside/nucleotide analogs (NA) is the standard post-transplant treatment; however, there are limitations in using HBIG, particularly its cost. We present two illustrative clinical cases as examples of post-transplant management using dual NA therapy, unaccompanied by HBIG.

CASE SUMMARY

The first case involves a 42-year-old man with HBV-related cirrhosis, who, in the context of a diagnosis of hepatocellular carcinoma and hepatopulmonary syndrome, underwent LT without viremia at the time of transplantation. A lack of availability of HBIG led to the combined use of two NAs, entecavir, and tenofovir alafenamide—resulting in the negativization of hepatitis B surface antigen (HBsAg) and maintenance of a negative viral load in the post-transplant period. In the second case, a 63-year-old woman presented with acute hepatic failure due to HBV with viremia during transplantation. Combined therapy with entecavir and tenofovir alafenamide, again due to the unavailability of HBIG, ultimately led to the negativization of HBsAg and viral load.

CONCLUSION

These cases suggest the efficacy of dual NA therapy in post-transplant HBV management, emphasizing the need to reconsider traditional treatment approaches.

Keywords: Antiviral drug; Liver transplant; Hepatitis B virus; Viral recurrence; Nucleoside analog; Case report

Core Tip: This manuscript explores post-liver transplant strategies for hepatitis B virus (HBV). Two cases showed the success of dual nucleoside/nucleotide analog (NA) therapy (entecavir and tenofovir alafenamide) without hepatitis B immunoglobulin (HBIG) in prevention of HBV recurrence. These cases emphasize the efficacy of dual NA therapy as a viable alternative in managing post-transplant HBV infection, especially when HBIG is unavailable. This challenges the standard protocol and proposes reconsidering post-transplant management when specific treatments are limited.