The UK experience with hepatitis B immunoglobulin use following liver transplantation: wide variation in practice despite evidence supporting cost-effective HBIG-free prophylaxis

INTRODUCTION: Hepatitis B immunoglobulin (HBIG) and nucleos(t)ide analogues (NA) are standard prophylaxis against hepatitis B virus (HBV) recurrence after liver transplantation (LT). However, indefinite HBIG use, with variations in dosage and duration across LT centres, has recently been questioned. This study reviewed current HBV management practices and outcomes after LT across the UK. METHODS: We conducted a retrospective study of all HBV-related LTs in the UK (2010-2023) to review post-LT HBV prophylaxis, assess the impact of HBIG duration on HBV recurrence and overall survival and compare HBIG costs across protocols. RESULTS: Significant variation in protocols among LT centres was observed. The majority of the 273 patients were high risk for HBV recurrence (81.7%). After LT, 85% received HBIG regardless of the risk for HBV recurrence and 54.6% of patients continued HBIG treatment with a median duration of 119 days (IQR 10-344). A total of 14 patients (5.1%) experienced HBV recurrence within 12 months following LT. Our multivariate analysis indicated that triple immunosuppression following LT had a significantly increased risk of HBV recurrence. Survival rates at 1, 5 and 7 years after LT were 98.2%, 88.3% and 80.6%, respectively. In the Cox regression analysis, only lower HBIG IV doses during the first week after LT were associated with 7-year mortality. CONCLUSION: There is a vast discrepancy in HBIG usage across the UK. HBIG doses after LT and the risk of HBV recurrence groups do not influence outcomes. HBIG maintenance-free prophylaxis is therefore a feasible and cost-effective option for most patients. Further prospective studies should verify these findings and support wider adoption of HBIG-free strategies.