UK liver transplant practice varies widely despite low hepatitis B recurrence
Across the UK, hepatitis B immunoglobulin use after liver transplantation remains inconsistent enough to change both cost and clinical practice from one center to the next. In this retrospective national analysis of hepatitis B virus–related liver transplants performed between 2010 and 2023, investigators reviewed prophylaxis strategies, recurrence rates, survival, and treatment costs in 273 patients. The central finding is hard to ignore: recurrence remained uncommon, even though most patients were considered high risk and prophylaxis protocols differed substantially.
A striking 81.7% of recipients fell into the high-risk category for HBV recurrence, yet 85% still received HBIG after transplant regardless of baseline risk. Even among those treated, continuation patterns were far from uniform. More than half of patients, 54.6%, remained on HBIG after transplantation, with a median duration of 119 days and an interquartile range stretching from 10 to 344 days. That spread captures the lack of consensus in plain numbers.
The biology behind the clinical question is familiar to transplant hepatology. HBIG provides passive neutralization of circulating HBV particles, while nucleos(t)ide analogues suppress viral replication at the source. In the modern era, potent antivirals have reduced the need for prolonged antibody-based prophylaxis, especially when viral suppression is durable and adherence is strong. The unresolved issue has been whether centers still need to layer HBIG on top of effective antiviral therapy for long periods after liver transplantation.
Recurrence remained uncommon even in a largely high-risk cohort
Within 12 months of transplantation, 14 patients experienced HBV recurrence, representing 5.1% of the cohort. In a population where the majority were already classified as high risk, that recurrence rate argues against a large incremental benefit from prolonged HBIG exposure in most patients. The study design cannot prove equivalence, but the event rate is low enough to make routine indefinite HBIG use difficult to justify on clinical grounds alone.
The analysis also examined whether the risk category itself, or the way HBIG was administered, changed outcomes in meaningful ways. HBIG doses after transplant and the recurrence-risk grouping did not influence outcomes in the final assessment. That finding matters because it suggests the prevailing instincts around more intensive or longer HBIG schedules may not translate into measurable protection for most recipients.
One result did cut in the opposite direction. Triple immunosuppression after liver transplantation was associated with a significantly increased risk of HBV recurrence in multivariate analysis. The signal is biologically plausible: deeper suppression of host immune control can weaken the residual barrier against viral rebound or occult infection reactivation. In a transplant recipient, the balance between preventing rejection and controlling HBV can shift quickly when the immunosuppressive burden rises.
Lower early IV HBIG exposure tracked with 7-year mortality
Longer-term outcomes were strong overall. Survival after liver transplantation reached 98.2% at 1 year, 88.3% at 5 years, and 80.6% at 7 years. Those figures reflect a cohort that did well despite considerable variation in prophylaxis strategy. In Cox regression analysis, only lower HBIG intravenous doses during the first week after transplant were associated with 7-year mortality.
The study does not establish causation, and the mortality association should not be read as a reason to intensify HBIG indiscriminately. Early postoperative dosing may simply be acting as a marker of a more complex clinical course, frailty, organ quality, perioperative instability, or other factors not fully captured in a retrospective dataset. Still, the signal deserves attention because it is the only HBIG-related variable that tracked with long-term survival in the analysis.
Viewed clinically, the contrast is sharp. More HBIG did not clearly reduce recurrence, and prolonged maintenance did not separate out as a necessary feature of better outcomes. The data point toward the opposite direction: prophylaxis can likely be simplified for most patients without sacrificing protection.
Cost pressure adds a practical reason to reconsider maintenance HBIG
The cost comparison strengthens the case for simplification. The study compared HBIG costs across protocols and found enough variation to make maintenance-free strategies economically attractive. HBIG is expensive, and when recurrence rates are already low under contemporary antiviral therapy, even modest reductions in unnecessary administration can translate into meaningful system-level savings.
This is not only a budget issue. Repeated infusions, prolonged treatment exposure, and protocol complexity all add burden for patients and transplant services. A simpler approach reduces opportunities for variation, delays, and confusion over when prophylaxis should stop. In a national transplant program, consistency matters almost as much as efficacy when the outcome differences are small.
The practical implication is straightforward. For many liver transplant recipients with HBV, HBIG-free prophylaxis appears feasible, effective, and cost-conscious when paired with nucleos(t)ide analogue therapy. The study’s findings support a move away from automatic long-term HBIG continuation, especially when recurrence risk is not translating into worse observed outcomes.
Prospective validation is still needed before protocols are rewritten everywhere
This was a retrospective analysis, and its limitations are inseparable from its strengths. Real-world practice across multiple UK centers provides a valuable national snapshot, but retrospective review cannot remove selection bias, center-level differences, or unmeasured confounding. The wide spread in HBIG dosing and duration also means clinicians were already making individualized decisions before the outcomes were known.
Even so, the core message is clinically coherent. Modern antiviral therapy appears to carry much of the prophylactic burden after liver transplantation, while HBIG contributes little for most patients beyond added cost and protocol complexity. The low recurrence rate, the lack of an outcome advantage tied to HBIG dose or risk category, and the feasibility of maintenance-free prophylaxis all point in the same direction.
Prospective studies will need to confirm which transplant recipients, if any, still benefit from prolonged HBIG and whether specific immunosuppression patterns should change monitoring or prophylaxis intensity. Until then, the UK experience offers a strong argument for narrower, less expensive HBIG use after liver transplantation, with careful attention to the small subset of patients whose clinical profile may still justify more intensive coverage.