Hepatitis B and liver transplantation: Challenges and advances

Abstract

While hepatitis B prevalence in sub-Saharan Africa exceeds 8% in many regions, access to liver transplantation on the continent remains limited to a handful of centres. This contrast between disease burden and therapeutic capacity shapes every aspect of HBV-related transplant care in South Africa. This research reviewed the outcomes of 155 liver transplants performed for HBV-related end-stage liver disease at the Cape Town Institute of Transplant Sciences between January 2013 and December 2022. Indications included decompensated HBV cirrhosis (41.3%), HBV-related hepatocellular carcinoma (28.7%), acute-on-chronic liver failure (14.2%), fulminant HBV hepatitis (8.4%), HBV-HDV co-infection (4.5%), and other HBV-related causes (2.9%). All recipients received combination prophylaxis with hepatitis B immunoglobulin (HBIG) and nucleos(t)ide analogues. The primary outcome was five-year graft survival. Overall five-year graft survival was 76.1%, with one-year and three-year rates of 88.4% and 81.3%, respectively. HBV recurrence, defined as reappearance of HBsAg or detectable HBV DNA post-transplant, occurred in 18 patients (11.6%). Pre-transplant MELD score above 25 was independently associated with graft failure (hazard ratio 2.14, p = 0.009). Among the 18 recurrence cases, 14 (77.8%) were salvaged with rescue entecavir or tenofovir therapy. These outcomes, while encouraging, lag behind reported five-year survival rates of 80-85% in high-resource settings, reflecting challenges specific to the African context including delayed referral, limited organ availability, and higher rates of advanced disease at listing.