Emergence of Hepatitis B Infection Despite Antibodies to Hepatitis B Surface Antigen: A New Nosocomial Risk in Patients With End-Stage Renal Disease

Clinical practice guideline management of blood borne viruses within the haemodialysis unit

Some people who are receiving dialysis treatment have virus infection such as hepatitis B, hepatitis C and/or HIV that is present in their blood. These infections can be transmitted to other patients if blood is contaminated by the blood of another with a viral infection. Haemodialysis is performed by passing blood from a patient through a dialysis machine, and multiple patients receive dialysis within a dialysis unit. Therefore, there is a risk that these viruses may be transmitted around the dialysis session. This documents sets out recommendations for minimising this risk.There are sections describing how machines and equipment should be cleaned between patients. There are also recommendations for dialysing patients with hepatitis B away from patients who do not have hepatitis B. Patients should be immunised against hepatitis B, ideally before starting dialysis if this is possible. There are guidelines on how and when to do this, for checking whether immunisation is effective, and for administering booster doses of vaccine. Finally there is a section on the measures that should be taken if a patient receiving dialysis is identified as having a new infection of hepatitis B, hepatitis C or HIV.

Pitfall of hepatitis B surface antigen testing in a kidney transplant recipient presenting hepatitis B reactivation

Diagnosis of hepatitis B virus (HBV) infection based on hepatitis B surface antigen (HBsAg) detection can be hampered in the setting of HBV reactivation in immunocompromized patients with prior serology indicating past cured infection, and can be associated with severe or fulminant and fatal hepatitis. We present a case of HBV reactivation in a renal transplant patient in whom HBsAg failed to be confirmed as a true positive result. One year after transplantation, systematic testing showed HBsAg positivity with a titer at 244 pg/mL, anti-hepatitis B core antibody and concurrent anti-hepatitis B surface antibody positivity. Confirmation of HBsAg detection by seroneutralization did not confirm HBsAg positivity, indicating that HBsAg detection was a false positive result. Notwithstanding, HBV DNA titer in serum was concurrently 8.6 Log IU/mL. HBV DNA sequencing showed a genotype D and several amino acid substitutions within HBsAg, including some previously involved in impaired diagnosis and altered immunogenicity. Although no perturbation of liver biochemical markers was observed, treatment with tenofovir was introduced. One month later, HBV DNA level had decreased by 2.6 Log IU/mL and no clinical and biochemical symptoms of hepatitis had occurred. The present case underlines that serologic diagnosis of HBV reactivation can be tricky in transplant recipients with a prior serology indicating past HBV infection. This prompts to perform HBV DNA testing in case of positive HBsAg testing, regardless of the result of neutralization by anti-HBs antibodies.