O9 The UK experience of liver transplantation for HBV: results from a national audit

<h3>Introduction</h3> Hepatitis B immunoglobulin (HBIG) along with high genetic barrier Nuclos(t)ide analogues (NAs) are currently the standard care for prophylaxis against HBV recurrence post-liver transplantation (LT). However, indefinite HBIG therapy remains controversial, with heterogeneity between LT centres as to dosage and duration. We have aimed to audit the current management and outcomes of HBV post-LT at liver transplant centres across the UK. <h3>Method</h3> We conducted a retrospective, multicentre study through the British Association for the Study of Liver, including all patients who had LT for HBV between 2010 to 2023 in the seven UK LT centres. The primary outcome was to compare the duration of HBIG in different transplant centres and its relation to HBV recurrence, and the secondary outcome was to assess overall survival post-LT. <h3>Results</h3> 273 patients were included (79.1% male; median age 51 years). 25% had HBV/HDV coinfection. Common indications for LT were decompensated cirrhosis (44.7%) and hepatocellular carcinoma (HCC) (43.6%). At the time of LT, 67.8% had undetectable HBV DNA, and 63.7% with HBV/HDV coinfection had detectable HDV RNA. All patients received NAs post-LT, and 81% received HBIG post-LT regardless of HBV DNA at the time of transplant, with a total cost of £5.9 million. During an average follow-up of 5 years (± 0.4 SD), only 15 patients (5%) had HBV recurrence. Of these, 86.7% (n=13) had high risk of recurrence at the time of LT; 4 had HBV/HDV coinfection, 5 had HCC, and 4 had fulminant HBV. Out of 43 patients (15.7%) who did not receive HBIG post-LT; only 1 patient had HBV recurrence. The median survival post-LT was 54 months (range 0–159 months), and 38 patients died, of which only 2 deaths were due to HBV recurrence. Multivariate regression analysis showed no significant association between the number of HBIG doses in the first week post-LT, maintenance HBIG and HBV recurrence (P= 0.192, 0.619 respectively) or mortality (P= 0.301, 0.437 respectively). <h3>Conclusion</h3> HBV recurrence post-LT in the UK is not influenced by HBIG use, and survival following transplant, including HBV/HDV coinfected patients, is excellent. Prolonged maintenance of HBIG post-LT is neither cost-effective nor necessary, and almost all patients who did not receive HBIG did not experience HBV recurrence or an increase in mortality. Early withdrawal or HBIG-free prophylaxis should be a strategy in a risk-stratified manner, which should be robustly reflected in clinical practice guidelines. Further prospective studies should be conducted to confirm these results. <h3>References</h3> E World Health Organization. Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021 2021 Hepatitis B in England - 2023 report Working to eliminate hepatitis B as a public health threat, https://assets.publishing.service.gov.uk/media/63dba059d3bf7f0704f31d37/Hepatitis_B_in_England_2023.pdf Jia J, Li Y, Wei C, Guo R, Xu H, Jia Y, Wu Y, Li Y, Wei Z, Qi X, Qi X, <i>et al.</i> Factors associated with disease progression and viral replication in patients with chronic hepatitis B virus infection. <i>Exp Ther Med</i> 2019;<b>17</b>:4730–4740. Mckeating C, Cadden I, McDougall N, Jessop L, Quah S, Lavelle M, Griffths A, McCaughey C. Progression from acute to chronic hepatitis B is more common in older adults. <i>Ulster Med J</i>. 2018 Oct;<b>87</b>(3):177–180. Epub 2018 Oct 1. PMID: 30559541; PMCID: PMC6169415. Wang UJ, Li MW, Liu YN, Chen XM, Zhao JM, Liu SH, Lu FM. [Natural history and disease progression of chronic hepatitis B virus infection]. <i>Beijing Da Xue Xue Bao Yi Xue Ban</i>. 2022 Oct 18;<b>54</b>(5):920–926. Chinese. doi: 10.19723/j.issn.1671-167X.2022.05.019. PMID: 36241234; PMCID: PMC9568401. European Association for the Study of Liver 2017, EASL Clinical Practice Guidelines on the management of hepatitis B virus infection. <i>J Hepatol</i>. 2017;<b>67</b>(2):370–98. AASLD (to be added) British Transplantation Society Guidelines. Guidelines for Hepatitis B &amp; Solid Organ Transplantation 2018; https://bts.org.uk/wpcontent/uploads/2018/03