The unsuccessful attempts at liver transplantation in hepatitis B surface antigen (HBsAg)-positive patients performed during the 1970s² convinced the medical community that the procedure was to be considered as ‘not indicated’ for hepatitis B cirrhosis. The indication for liver transplantation was a matter for debate until the late 1980s due to the high recurrence rate and the unfavourable results in terms of patient survival compared with the other categories of patients with end-stage liver disease. However, during this period two clinical observations were published. The first concerns the use of passive hepatitis B immunoglobulins (HBIg) in the care of HBV liver transplant patients.^6–8 Although the exact modalities by which HBIg protects the graft from re-infection have not been completely elucidated (i.e. either by binding the circulating virions⁹ or by blocking the HBV receptor on liver cells¹⁰), passive immunoprophylaxis represents the cornerstone in medical therapies associated with liver transplantation in HBV. The second observation concerns the routine use of a molecular hybridisation technique to assess the level of HBV replication. Both of the approaches allowed the indication of liver transplantation in HBV to spread to patients all over the world. The results obtained were further improved with the implementation of new strategies. The most important intuition was that better results can be obtained when transplantation is performed at a low level of viral replication.¹¹ The identification of this small set of patients and the periodic infusion of anti-HBs immunoglobulins were awarded with satisfactory results in terms of a low recurrence rate.

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