Updates in antiviral management of hepatitis B after liver transplantation

Prophylaxis combining hepatitis B immunoglobulin (HBIG) and nucleos(t)ide analogues (NAs) has dramatically reduced post-liver transplantation (LT) hepatitis B virus (HBV) recurrence.With the advent of potent, high-genetic-barrier NAs-entecavir, tenofovir disoproxil fumarate, and tenofovir alafenamide-contemporary management is shifting from uniform lifelong combination therapy toward risk-stratified minimization.Indefinite high-barrier NA therapy forms the cornerstone of this strategy, with specific agent selection guided by prior resistance profiles alongside renal, bone, and metabolic considerations.In adherent recipients at low risk of recurrence, current guidelines support short-course HBIG or HBIG-free prophylaxis.Prolonged combination prophylaxis is generally recommended for higher-risk recipients, including those with detectable HBV DNA at LT or hepatitis D virus or human immunodeficiency virus coinfection.In donor-derived settings involving hepatitis B core antibody (anti-HBc)-positive or hepatitis B surface antigen (HBsAg)-positive grafts, preventive strategies are guided by both donor and recipient HBV serological profiles, with high-barrier NAs playing a central role.While HBIG withdrawal with continued NA therapy is supported in selected recipients, complete withdrawal of prophylaxis after LT for HBV-related disease remains investigational.In conclusion, post-LT HBV management should be individualized by balancing virological risk, recipient comorbidities, adherence, and close monitoring.