Since the early 1990's,
hepatitis B immune globulin (
HBIG) has been central to the prevention of hepatitis B virus (HBV) recurrence after
liver transplantation. When used in combination with oral nucleos(t)ide analogues,
HBIG prevents
reinfection with HBV in ⩾90% of transplant recipients. While
HBIG is highly efficacious, its use is undermined by its high cost. Because of this limitation, there have been many studies of alternative regimens seeking to minimize the dose or duration of
HBIG without sacrificing low HBV recurrence rates. Toward that goal, lower dose intramuscular
HBIG in combination with oral nucleos(t)ide analogues has been shown to be highly efficacious in preventing disease recurrence and represents a significant cost savings when compared with high dose
intravenous administration. The withdrawal of
HBIG after a defined course of combination
HBIG and oral
antivirals has also been shown to be effective, particularly if combination
antiviral therapy is used. The ability to achieve undetectable HBV
DNA levels pre-
transplantation in the majority of patients may contribute to the high efficacy of these
HBIG "light" regimens. Additionally, the success of
antiviral rescue
therapy for those patients who fail prophylaxis and develop recurrent HBV
infection post-transplant has provided the impetus to move increasingly towards
HBIG-free approaches. New techniques to detect occult HBV in hepatic and extrahepatic sites may allow clinicians to define a subgroup of patients in whom withdrawal of
HBIG or all prophylaxis may be applicable.