UCSFMC Guidelines for Management of HBV in Immunosuppressed/Transplant Recipients

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UCSF Joint Hepatology/Transplant ID Guidelines For Anti-HBc+ Management In Organ Transplantation and Immunosuppression

For questions please contact Hepatology (LTU pager 207-1666) or Transplant ID (443-2552). For pediatric patients, contact Lynn Ramirez (lynn.ramirez@ucsf.edu) or Rachel Wattier (rachel.wattier@ucsf.edu).

PART I: Management of HBsAg– Transplant Recipients with anti-HBc+ Donors (Non-liver)

Recipient Status

Prophylaxis?1

Duration

Monitoring (HBsAg, HBV DNA, LFTs)

anti-HBc– anti-HBs+

No

n/a

Q3mo x 1 yr (also check for loss of anti-HBs)

anti-HBc+

See table below for management of anti-HBc+ recipients.

anti-HBc– anti-HBs–

Kidney: yes2

At least 1 year

Q3mo until 1 yr after d/c antivirals

Heart or lung: no

n/a

Q3mo x 1 yr

1The preferred antiviral is lamivudine. If the donor is HBV DNA positive then always use entecavir.
2Only kidney and liver recipients have been shown to reactivate in this situation. Ultimate duration of ppx depends on results of

monitoring labs and patient’s net state of immunosuppression.

Note: Pediatric organ transplantation from anti-HBc+ donors is NOT currently recommended due to lack of data for safety in children; if transplantation from an anti-HBc+ donor is being considered under exceptional circumstances, consult with Pediatric ID.

PART II: Management of HBsAg– anti-HBc+ Patients Receiving Immunosuppression (anti-HBs– or +)

Type of Immunosuppression

Prophylaxis?1

Duration

Monitoring (HBsAg, DNA, LFTs)

Rituximab

Yes

24 mo after last dose

Q3mo until 1 yr after d/c antivirals

Anti-TNF

Consider2

6 mo after last dose

Q3mo until 1 yr after d/c antivirals (or equivalent time period if no ppx)

Steroids

No3

 

Q3mo x 18 mo after last dose

Chemotherapy (solid tumor)

No4

 

Q3mo x 18 mo after last dose

SOT recipients (non-liver)

Yes

12 mo

Q3mo x 2 years

SOT recipients (non-liver) with thymoglobulin for rejection

Yes

12 mo after thymo dose

Q3mo until 1 yr after d/c antivirals

HSCT

Yes

Long term5

Q3mo

AML/ALL and myeloablative chemotherapy

Yes

Long term5

Q3mo

1The preferred antiviral is lamivudine. If the patient is HBV DNA-positive, then use entecavir for prophylaxis. Duration should be reassessed based on monitoring labs and net state of immunosuppression. Note: liver recipients receive lifelong ppx.

2Data is conflicting for anti-TNF: studies show a risk of 0-5% reactivation in anti-HBc+ patients. AGA guidelines recommend ppx in this situation although other guidelines do not. Clinical correlation advised.

3Most guidelines do not recommend ppx for steroids, although the AGA guidelines do recommend it for prednisone 10mg/day for 4 weeks, for a duration of 6 months after last dose. Clinical correlation advised.

4Most guidelines do not recommend ppx for solid tumor chemotherapy, although AGA guidelines do recommend it for anthracycline- based chemo, for a duration of 6 months after the last dose. Clinical correlation advised.

5Prophylaxis should be for at least 2 years, and some experts recommend indefinite prophylaxis.

For HIV-positive patients requiring prophylaxis: follow DHHS guidelines for the treatment of HIV/HBV coinfection: use tenofovir (TDF or TAF) with FTC or 3TC. Do not use 3TC or FTC alone for prophylaxis given the risk of resistance.

Last updated May 2017.

 

References/Guidelines:

  •  Huprikar et al, Solid Organ Transplantation From Hepatitis B Virus–Positive Donors: Consensus Guidelines for Recipient Management. Am J Transplant 2015; 15:1162.

  •  Reddy et al, AGA Institute Guideline of the Prevention and Treatment of Hepatitis B Virus Reactivation During Immunosuppressive Therapy. Gastroenterology 2015; 148:215.

  •  Perrillo et al, AGA Technical Review of Prevention and Treatment of HBV Reactivation During Immunosuppressive Drug Therapy. Gastroenterology 2015; 148:221.

  •  Bisceglie et al, Recent US Food and Drug Administration Warnings on Hepatitis B Reactivation With Immune- Suppressing and Anticancer Drugs: Just the Tip of the Iceberg? Hepatology 2015; 61:703).

  •  Levitsky et al, Viral Hepatitis in Solid Organ Transplantation. Am J Transplant 2013; 13:147.