Liver transplantation for HBV-related liver disease. Impact of prophylaxis for HBV on HCC recurrence

Background and aims Conflicting data exist regarding optimal prophylaxis for HBV recurrence (HBV-R) after liver transplantation (LT), particularly in patients with hepatocellular carcinoma (HCC). We assessed current practices for HBV-R prophylaxis in Italy, evaluating rates, risk factors, and clinical impact of HBV-R and HCC-R. Methods Multicentric, retrospective study involving 20 Italian LT centers. All patients who underwent LT for HBV-related liver diseases between 2010 and 2021 were included. Logistic regression was used to identify predictors of HBV-R and HCC-R. Survival curves were estimated with Kaplan-Meier method and compared with log-rank test. Results We included 1205 LT recipients (60.8% HCC). HBV prophylaxis was prescribed in 99.7% recipients, mostly with lifelong HBIG+NUCs (83.9%). Rates of HBV-R were 2.1% and 3.1% in patients transplanted without and with HCC, respectively. Median times from LT were 60 [9.5–77.5] and 5.5 [1–13] months, respectively. Recipients on lifelong HBIG+NUCs experienced lower rates of HBV-R than those in whom HBIG were withdrawn, used only during LT, or received NUCs alone (2.3% vs. 6.2% vs. 1.9% vs. 8%, respectively; p=0.042). In HCC recipients, HCC-R rate was 10.8% (median time from LT: 18 months). At multivariate analysis, HBV-R (OR: 10.329; 95%CI: 3.665-29.110), Child-Pugh C (OR: 3.519; 95%CI: 1.305-9.484), and microvascular invasion (OR: 3.088; 95%CI: 1.692-5.634) were independently associated with HCC-R. Five-year survival was lower in recipients who experienced HCC-R (32.5% vs. 92.4% in those who did not; p<0.001). Conclusion In Italy, HBV prophylaxis is mostly based on lifelong HBIG+NUCs. HBV-R was rare and not associated with survival in patients transplanted for decompensated cirrhosis. In patients transplanted for HCC, HBV-R was independently associated with HCC-R. The clinical implications of these findings deserve further investigation.