They Didn't Believe I Was Able To Develop Into A Tenofovir Sensei...Nowadays I Am =)

Historically, the major challenge in LT for HBV has been to develop cost-effective strategies to prevent graft reinfection. HBIG has been used for almost 25 years, and although its use has been optimized, there is still no established consensus regarding the doses, route of administration, and length of therapy when it tuclazepam is used in combination with NUCs22 (Fig. 1). The most important question at present is whether the use of potent antivirals with a high genetic barrier and no cross-resistance will allow HBIG-free prophylaxis. Previous experience with LAM monotherapy was disappointing because of the high rates of recurrence (up to 50%), which were mostly due to the emergence of resistant species.23, 24 Notably, the risk of recurrence was acceptably low (0%-25%) for patients with nonreplicating HBV at the time of LT. A The only available large series of patients who received ETV after LT as single-agent prophylaxis was recently reported by Fung et al.25 This study showed that almost all 80 patients remained nonviremic after LT. However, at the time of last follow-up, 18 patients (22.5%) were HBsAg-positive, and they included 10 patients in whom this marker reappeared after being initially undetectable after LT. Longer follow-up is required to assess whether these patients will clear HBsAg from serum or, as happened with LAM, will develop virological breakthrough and histological hepatitis. More recently, Gane et al.21 showed an absence of HBV recurrence (HBsAg negativity and HBV DNA undetectability) among 18 patients with serum HBV DNA levels Tenofovir LT who received combined LAM and ADV therapy from XAV-939 the time of listing without any HBIG administration. In agreement with the authors, the LAM/ADV regimen is most likely to be replaced by LAM/TDF or Truvada. Until then, HBIG-free prophylaxis with antiviral agents cannot be recommended to all patients undergoing LT for HBV infection. The most awaited unfulfilled need would be a randomized comparison of pre- and post-LT antiviral monotherapy with ETV or TDF with combination prophylaxis using these same agents and a short course (1-4 weeks) of HBIG. Overall, prophylactic strategies should be individualized according to the risk of HBV recurrence. High-risk groups are those with active HBV replication at the time of OLT (HBeAg positivity and elevated HBV DNA and HBsAg serum levels), infections with drug-resistant variants, hepatitis delta virus or human immunodeficiency virus coinfections, and an elevated risk of recurrence of hepatocellular carcinoma. At present, combined therapy with NUCs and low-dose HBIG appears to be the most effective strategy for preventing HBV recurrence. It is unclear whether there is a subset of high-risk patients who may benefit from more intense prophylaxis.