Short communication
HBV reactivation after kidney transplantation

https://doi.org/10.1016/j.jcv.2004.10.006Get rights and content

Abstract

Recent studies suggest that reappearance of hepatitis B surface antigen (HBsAg) and loss of anti-HBs antibodies may be common events in bone marrow recipients and patients with chemotherapy. In this study, we reviewed the virologic laboratory records from kidney recipients. Out of 1512 patients, 228 had been diagnosed with resolved HBV infection (anti-HBc positive, HBsAg negative) but normal liver enzyme levels prior to kidney transplantation. Reappearance of HBsAg after kidney transplantation was observed in two (0.9%) of those patients, which may be attributed to reactivation of a latent infection or to a new HBV infection. In both of the patients, HBV infection may have been reactivated although immunosuppression was just on a low level over the whole period. We conclude that natural immunity to HBV may not protect against reactivation in patients with suppression of the immune system. Periodic follow-up of HBV serology for early diagnosis of reactivation is highly recommended in transplant recipients.

Introduction

In transplant recipients, hepatitis B virus (HBV) infection is associated with significant morbidity and mortality by cirrhosis or hepatocellular carcinoma. Immunosuppression increases the risk of HBV reactivation, defined as reappearance of the ‘e’ antigen (HBeAg) in the serum of hepatitis B surface antigen (HBsAg) positive patients. In bone marrow transplant recipients and patients undergoing chemotherapy with previously resolved HBV infection, reappearance of HBsAg and loss of anti-HBsAg were described in several case reports (Lok et al., 1991, Martin et al., 1995; Knöll et al., 2004). In solid organ recipients, however, reactivation seems to be a rather rare event and is not well described in the literature. Here, we report the occurrence of HBV reactivation in two kidney transplant recipients.

Section snippets

Case report

In this study, we reviewed virologic laboratory records of kidney recipients. Out 1512 patients, 228 had been diagnosed with resolved HBV infection (anti-HBc positive, HBsAg negative) but normal liver enzyme levels prior to kidney transplantation. Reappearance of HBsAg after kidney transplantation was observed in two (0.9%) of those patients.

The first patient was a 75-year old man who was dialysed from 1985 onwards because of polycystic kidneys. In 1988, he received a kidney from a donor who

Discussion

We describe two transplant patients with serological evidence of resolved HBV infection in whom HBsAg reappeared after transplantation. Reappearance of replicating HBV in patients with resolved infection may be caused by re-infection, especially in the setting of hemodialysis. In this study, we were not able to compare the sequences of the HBV strains responsible for the initial infection to those ones appearing after transplantation. It, however, may be most likely a result of viral

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    Vaccinate all susceptible patients for HBV if the HBV panel is negative for all 3 markers. Recipients who are HBsAg negative and anti-HBc positive have an up to 5% risk of reactivation after renal transplantation unrelated to HBV DNA viral load before transplantation.31–33 A retrospective study of 322 HBsAg-negative, anti-HBc–positive, HBV DNA-negative patients reviewed all kidney transplant recipients at the First Affiliated Hospital of Sun Yat-sen University in China between January 1998 and June 2008.

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    Hepatitis B virus (HBV) infections still represent a significant cause of morbidity and mortality in kidney transplant recipients (KTRs) [1]. In addition to recipients with chronic HBV infection at the time of transplantation, other patients with past resolved HBV infection can experience HBV reactivation, mostly when they are devoid of anti-hepatitis B surface antigen antibodies (anti-HBsAb) [2–6]. Moreover, KTRs who are not immunized against HBV are at risk for de novo HBV infection through potential risks including graft, blood products transfusion and hemodialysis.

  • Reactivation of Hepatitis B virus in kidney transplant recipients with previous clinically resolved infection: A single-center experience

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    Reported rates of reactivation are variable; while some authors claim that the risk is negligible regardless of anti-HBs status,6 others have published rates ranging from 1 to 6.5%.7,8 It has been suggested that in these patients the presence of anti-HBs antibodies may provide protection against HBV reactivation8–10 but there are too few data about the proportion of renal transplant patients with resolved HBV infection and with positive anti-HBs titers that lose immunity during follow-up.11 Thus, it remains unclear regarding what kind of monitoring is needed and whether these patients would benefit from antiviral prophylaxis during the post-transplant period.

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Presented in part at the fifth international symposium on molecular diagnostics in Laboratory Medicine, Graz, Austria, June 10–12, 2004.

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