Abstract

The literature on hepatitis B virus (HBV) in immunocompromised patients is heterogeneous and referred mainly to the pre-antivirals era. Today a rational approach to the problem of hepatitis B in these patients provides for: (a) the evaluation of HBV markers and of liver condition in all subjects starting immunosuppressive therapies (baseline), (b) the treatment with antivirals (therapy) of active carriers, (c) the pre-emptive use of antivirals (prophylaxis) in inactive carriers, especially if they are undergoing immunosuppressive therapies judged to be at high risk, (d) the biochemical and hepatitis B surface antigen (HBsAg) monitoring (or universal prophylaxis, in case of high risk immunosuppression) in subjects with markers of previous contact with HBV (HBsAg negative and anti-HBc positive), in order to prevent reverse seroconversion.

Moreover it is suggested a strict adherence to criteria of allocation based on the virological characteristics of both recipients and donors in the general setting of transplants and in liver transplantation the universal prophylaxis with nucleos(t)ides analogues (frequently combined with specific anti-HBV immunoglobulins) in HBsAg positive candidates and in HBsAg negative recipients of anti-HBc positive grafts.

Keywords: Antivirals; HBV; Immunosuppression; Transplants

Abbreviations: ABVD, Doxorubicine, Bleomycin, Vinblastine, Dacarbazine (standard therapy for Hodgkin lymphoma); anti-core, an HBsAg negative/anti-HBc positive subject; anti-HBc, antibody to hepatitis B core antigen; anti-HBe, antibody to hepatitis e antigen; anti-HBs, antibody to HBsAg; ART, anti-retroviral therapy; CHOP, Cyclophosphamide, Doxorubicin, Vincristine, Prednisolone; D, donor; GvHD, Graft versus Host Disease; HAI, histology activity index; HBeAg, hepatitis B envelope antigen; HBIG, anti-HBV specific immunoglobulins; HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; HCV, hepatitis C virus; HDV, hepatitis D virus; HIV, human immunodeficiency virus; HSCT, haematopoietic stem cells transplantation; IFN, interferon; INR, international normal ratio; MOF, multi organ failure; NAs, nucleos(t)ides analogues; PCR, polymerase chain reaction; PNLG, Piano Nazionale Linee Guida (National Guidelines); R, recipient; RCTs, randomized controlled trials; T, therapy; TNF, tumor necrosis factor; TP, targeted prophylaxis; UP, universal prophylaxis; US, ultrasound; VOD, veno-occlusive disease; YMDD, lamivudine-resistant mutants in locus YMDD of the polymerase gene

Article Outline

1. Introduction

2. Definitions

2.1. Virological characteristics

2.1.1. HBV carriers (HBsAg positive)

2.1.2. Occult HBV carriers (HBsAg negative)

2.2. Virological events

2.3. Clinical definitions

3. Treatment strategies

4. Treatment options

5. Monitoring

6. Impact on different specialist fields

7. Oncology, haematology and haematopoietic stem cell transplantation (HSCT)

7.1. Background

7.2. Experiences in the different virological categories

7.2.1. Active HBsAg-carriers

7.2.2. Inactive HBsAg-carriers

7.2.3. Anti-core patients (HBsAg negative)

7.3. Statements

7.4. Effects of different virological conditions in donors (D) and recipients (R) of allogeneic-HSCT

7.5. General statements in HSCT

8. Dialysis and solid organs transplants (kidney, heart and lung)

8.1. Background

8.1.1. Dialysis

8.2. Clinical experiences in nephrology

8.3. Statements in relation to transplant recipients

8.3.1. Active carrier

8.3.2. Inactive carrier

8.3.3. Anti-core recipient

8.4. Statements in relation to transplant donors

8.4.1. Anti-core donors

8.4.2. HBsAg positive donors

9. Liver transplantation

9.1. Background

9.2. Statements in relation to recipients

9.3. Statements in relation to donors

10. Rheumatology

10.1. Background

10.2. Statements

10.3. Peculiar conditions in the rheumatology setting

10.3.1. Anti-HBV vaccination

10.3.2. Panarteritis nodosa (PAN)

11. HIV

11.1. Background

11.2. Statements

11.2.1. Patients undergoing antiretroviral viral therapy (ART)

11.2.2. Patients who do not require ART

12. Conclusions

Conflict of interest statement

Acknowledgements

Appendix A. Appendix

References