Reactivation of Hepatitis B After Kidney Transplant in a Patient with Resolved Hepatitis B Infection and Review of Literature

Abstract

Introduction: Hepatitis B infection is associated with significant morbidity and mortality in kidney transplant recipients (KTRs). Immunosuppression after kidney transplant (KT) affect T- and B- cell functions which plays an important role in maintaining immunological memory against hepatitis B infection. The reported incidence of reactivation varies from 0%-6.5% in KTRs. We present a case of resolved hepatitis B infection confirmed with negative hepatitis B surface antigen (HBsAg) and positive hepatitis B surface antibody (HBsAb) with a titer of < 100 IU/L who had reactivation of hepatitis B 5 months after kidney transplant. Case presentation: A 54-year-old male from Nigeria migrated 30 years ago with end-stage renal disease underwent cadaveric renal transplant. The patient had history of resolved hepatitis B infection confirmed biochemically and serologically. His lab work during KT showed negative HBsAg, positive HBsAb with a titer of 16.4 IU/L, positive hepatitis B core total antibody (HBcAb), negative Hepatitis B e-antigen (HBeAg) and positive Hepatitis B e-antibody (HBeAb). Hepatitis B virus (HBV) DNA was not detected by polymerase chain reaction (PCR) technique. Liver function test (LFT) was completely normal. The donor organ was free of hepatitis B infection. 5 months after KT, he presented with AST-844 IU/L, ALT- 1787 IU/L, ALP- 206 IU/L, TB- 12.2 mg/dl and INR- 3. HBV serology showed positive HBsAg, negative HBsAb, negative hepatitis B core IgM antibody (HBcIgMAb), positive HBcAb, negative HBeAg, positive HBeAb. HBV DNA was detected by qualitative PCR and viral load was found to be 1,550,000 IU/mL. Discussion: Kanaan et al. observed that patients who lost their HbsAb after KT had a pre-transplant antibody titer below 100 IU/L (like our patient) and there was no reactivation in patients with antibody titer >100 IU/L. Savas et al reported two cases of reactivation whose titer level of HbsAb were 12 IU/ml in one case and 33IU/ml in another. Based on these observations, we encourage physicians to consider raising the HBsAb titer to >100 IU/L prior to KT and maintaining at that level in post-transplant period.