S2569 Rates of Hepatitis B Immunity in Patients Listed for Liver Transplant: Room for Improvement

Introduction: Guidelines advise hepatitis B virus (HBV) vaccination in all patients with chronic liver disease. For transplant centers that utilize HBV surface antigen-positive grafts, adhering to this recommendation is particularly important in transplant-eligible patients. Immunity protects a vulnerable population from hepatic decompensation, hepatocellular carcinoma, and donor-derived HBV infection. Methods: For quality assessment/improvement of our transplant program’s HBV immunity rates, serology collection, and vaccination process, we collected demographic data and HBV serologies from charts of liver transplant recipients who met inclusion criteria our single-center institution between 2022 and 2024. For the subset of patients who had received initial pre-transplant evaluations in the outpatient (vs inpatient) setting, additional data on serology timing, follow-up, vaccination attempts, and lab frequency were collected. Results: Of 219 liver transplant recipients included, 145 (66.2%) underwent outpatient transplant evaluation and 74 (33.8%) underwent inpatient evaluation. Only 37.4% of recipients were adequately immune to HBV at transplant. Outpatients were associated with lower immunity rates than inpatients (34.5% vs 43.2%). Of those who received outpatient evaluations, majority (93.8%) had documented HBV serology within 12 months of evaluation; 69.1% were non-immune at initial testing, yet only 29.8% of these received follow-up action. Over one-fifth (21.4%) of initially immune patients lost immunity by transplant. The median interval of HBV serology reassessment while on the waitlist was 8 months (IQR 4-20 months). Conclusion: Despite national guidelines to achieve HBV immunity in patients with chronic liver disease, a minority fraction (33.8%) of liver transplant recipients were immune to HBV at transplant at our institution. While national averages vary, these findings align with other U.S. liver transplant centers. Patients who undergo initial transplant evaluations in the outpatient setting represent an actionable population for HBV vaccination in the case of inadequate surface antibody titers. Barriers include care coordination for a 3-dose series, disjointed care across multiple hospital systems for complex patients, and known suboptimal HBV vaccine response in patients with cirrhosis. On-site hepatitis vaccinations in transplant clinics and improved inpatient vaccination efforts are validated ways to help address these challenges.