Optimization of hepatitis B virus prophylaxis after liver transplantation

A combination of hepatitis B immunoglobulins (HBIg) and nucleos(t)ide analogues (NA) is currently recommended for HBV prophylaxis after liver transplantation (LT), but the optimal regimen is still controversial. Several issues concerning use of HBIg after LT still await definitive clarification, such as dosage (high vs. low); timing (ab initio vs. delayed); schedule (on demand vs. fixed-dose); route of administration (intravenous vs. intramuscular vs. subcutaneous), and duration (short-term vs. long-term vs. lifelong). Alongside efficacy, issues concerning patients' safety and adherence, costs, and resource consumption should be part of the post-transplant decision algorithm to achieve optimization of anti-HBV prophylaxis and maximization of graft and patient survival. Based on the available data, HBIg withdrawal after LT needs to be validated in the long term. On the other hand, a monthly, fixed, low-dose HBIg schedule currently seems the solution to increase the cost–benefit ratio of combination prophylaxis regimens post-transplantation.