All anti-HBc-positive, HBsAg-negative dialysis patients on the transplant waiting list should be regarded as at risk of hepatitis B reactivation post-renal transplantation--report of three cases from a single centre

Abstract

Active hepatitis B (HBV) infection is associated with increased morbidity, mortality and reduced graft survival after renal transplantation, and one source of virus is reactivation of a previous infection. Traditionally, hepatitis B surface antigen (HBsAg)-negative patients with isolated hepatitis B core antibody (anti-HBc) are thought to have no risk of reactivation; indeed, isolated anti-HBc antibodies are often regarded as indicating a false positive result in dialysis patients. However, we describe three cases of hepatitis B post-renal transplantation in which no other source of virus could be found, despite detailed clinical and laboratory investigation. Two patients had no evidence of viral replication by polymerase chain reaction (PCR) at the time of transplantation. On analysis, 13% of the patients on our transplant waiting list were anti-HBc-positive, HBsAg-negative, all of whom were HBV DNA-negative by PCR. There are no guidelines for how to deal with these patients, but our experience suggests that until more is understood to allow discrimination of those patients at high risk, all anti-HBc-positive dialysis patients awaiting transplantation should be treated as at risk of reactivation following immunosuppression. We call upon national societies to update guidelines to incorporate advice on best practice for these patients. In the meantime, we recommend that all units identify this group to allow pre-transplantation counselling and post-transplantation antiviral prophylaxis to minimize these risks.