Introduction

Given the shortage of donor organs, hepatitis B core antibody positive (HBcAb+) donors have been utilized to increase access to transplantation. It is well established that recipients of a HBcAb+ liver are at risk for hepatitis B (HBV) reactivation post-transplant; 3% overall. Post-transplant anti-HBV prophylaxis is recommended in this population. Recommended regimens include antiviral agents (i.e. lamivudine, entecavir), sometimes with adjunct hepatitis B immune globulin (HBIG). However, lamivudine is no longer considered first line treatment for HBV given poor long term resistance rates. Which raises the question: What is the optimal regimen to prevent HBV reactivation in a post-transplant patient with a HBcAb+ donor? We present a case report where a family member of a HBcAb+ liver transplant recipient presented with acute HBV.

Material

A 38 y/o. male has a history of cirrhosis secondary to autoimmune hepatitis status post orthotopic liver transplant in 2011. Prior to his liver graft he tested negative for HBV surface antibody, core antibody, and surface antigen. The liver graft was from a HBcAb+ donor, and he was started on renally dosed lamivudine and HBIG. HBIG ceased in July 2012. In July 2013, HBV surface antigen was negative with an undetectable HBV DNA. He was given prednisone 40mg for 3 days for bronchitis in February 2016. In June 2016 his wife presented to the ER for jaundice and malaise and was found to have an acute HBV infection. An investigation found that her husband had a HBV viral load of >170 million international units per ml. His transaminases remained within normal limits, AST 17 and ALT 20. He denied missing doses of lamivudine, and there were no other HBV exposure risk factors for either partner.

Discussion

Lamivudine with short or long duration HBIG has been well studied as prophylactic therapy for HBcAb+ liver transplant recipients. Because HBV reactivation may occur without transaminitis, we propose that patients whom receive a HBcAb+ graft receive periodic monitoring of HBV DNA levels, and that further guidance is needed for optimal monitoring intervals. With lamivudine resistance rates at 5 years up to 65% in the pre-transplant population, HBcAb+ liver transplant recipients without demonstrated resistance to lamivudine may need to consider switching to a regimen with a better long term resistance profile. In addition, close family members should be vaccinated for HBV in case of reactivation.

CITATION INFORMATION: Gripshover J, Hidalgo K, Ravichandran B. Spousal Transmission of Hepatitis B from a Hepatitis B Core Antibody Positive Liver Transplant Recipient – A Case Report. Am J Transplant. 2017;17 (suppl 3).

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