False-Positive Hepatitis B Antigenemia After Vaccination in a Patient With CKD

Abstract

Iatrogenic blood-borne virus transmission in dialysis units has been recognized as a concern since the early days of hemodialysis.1 The prevalence of hepatitis B infection has steadily declined over the years, however, due to infection control measures, including physical isolation, environmental disinfection, and dedicated dialysis equipment for seropositive patients. Blood product screening and reduced transfusion requirements due to erythropoietin use have reduced viral transmission from infected blood products. Patient and staff vaccination against hepatitis B have also helped to reduce iatrogenic transmission.1 In patients with advanced chronic kidney disease (CKD) and in patients supported with long-term hemodialysis, hepatitis B vaccination is routine. However, advanced CKD has been associated with reduced immunogenicity, and only 50% to 70% of hemodialysis patients develop a protective antibody response after hepatitis B vaccination.2,3 Strategies that have been used to improve the seroconversion rate include doubling the vaccine dose, increasing the number of vaccine doses, and starting vaccination at an earlier stage of CKD.4 National guidelines have recommended the screening of hepatitis B serology for dialysis patients as part of infection control recommendations. While hepatitis B screening every 6 months is commonly reported, there is no consensus on the frequency of hepatitis B screening, with some guidelines advocating monthly screening for nonimmune patients.5 The development of new-onset hepatitis B antigenemia in a hemodialysis patient is significant and requires a rapid review. Iatrogenic transmission of hepatitis B is the most worrisome diagnosis, necessitating contact tracing and review of infection control measures to detect any lapses. However, a more benign cause is that of postvaccination transient hepatitis B antigenemia, which has been reported sporadically in dialysis patients since the 1990s.6, 7, 8 This creates a conundrum for physicians, in particular medical directors of dialysis units, because hepatitis B antigenemia could represent either of the 2 possibilities. In this report, we discuss our case series of 5 patients with CKD who developed transient false-positive hepatitis B antigenemia closely related to vaccination.