Viral hepatitis after liver transplantation: A brief overview

Abstract

Liver transplantation (LT) remains the only curative therapy in patients with end stage liver disease. With improvement in surgical techniques and immunosuppression protocols, both 1-year and 5-year survival have improved significantly. Similarly, recurrent hepatitis B virus and hepatitis C virus infection and consequent graft failure have become a thing of the past in the last few decades with the availability of highly effective nucleotide analogues and directly acting antivirals, respectively. However, infection with non-hepatotrophic viruses (e.g., cytomegalovirus and Epstein-Barr virus) remains an important cause of graft failure and rejection, leading to increased morbidity and mortality. Chronic hepatitis E virus infection is also an emerging cause of viral hepatitis and liver failure in these patients. The key to successful management is early diagnosis and institution of appropriate antiviral therapy. In addition, the immunosuppression must be modified to maintain a balance between aggravating viral infection and rejection. The key purpose of this article is to provide an updated overview of various hepatotropic and non-hepatotropic viral hepatitis in patients undergoing LT. Risk factors, Clinical presentation, and diagnosis of viral hepatitis in LT settings will be discussed in detail. Recurrent hepatitis B virus and hepatitis C virus infection in transplanted grafts will also be described. Finally, the use of vaccination and immunoglobulin to prevent the development of these infections will also be described.

Keywords: Viral hepatitis; Hepatotropic virus; Liver transplantation; Cytomegalovirus disease; Post-transplant lymphoproliferative disorders

Core Tip: Effective management of viral hepatitis after liver transplantation hinges on early diagnosis, vigilant monitoring, and timely antiviral therapy. For hepatitis B virus, nucleos(t)ide analogues with high genetic barriers to resistance (e.g., entecavir, tenofovir alefnamide/tenofovir disoproxyl fumarate) are preferred, often with short-term hepatitis B immunoglobulin in high-risk patients. Directly acting antivirals have revolutionized treatment of patients with hepatitis C virus infection. Though timing of treatment must balance the baseline model for end stage liver disease score and graft outcomes. Hepatitis E virus infection should be suspected in unexplained graft dysfunction; ribavirin is effective when reduction of immunosupression fails. Recurrence with hepatitis D virus infection is rare if hepatitis B virus is well controlled. Infection with cytomegalovirus and Epstein-Barr virus require prophylaxis, pre-emptive monitoring, and individualized immunosuppression adjustment to reduce risk of post-transplant lymphoproliferative disorder (related to Epstein-Barr virus infection) and graft loss.