*Purpose: Infectious transmission via solid organ transplant (SOT) remains an inherent risk of transplantation despite measures to mitigate the risk. We report a rare case of donor transmission of Hepatitis A virus (HAV) after deceased donor kidney transplant (DDKT) resulting in symptomatic hepatitis in both recipients.

*Methods: A 51 yo white female (A) and 59 yo white male (B), underwent DDKT from a same donor. Both recipients had uncomplicated surgical course, received thymoglobulin induction and standard immunosuppressive regimen, and after recovering from initial delayed graft function achieved excellent allograft function. However, patient A had constitutional symptoms (fatigue, nausea, vomiting, and diarrhea) which persisted despite appropriate interventions. By 8wk post-DDKT, her systemic symptoms worsened with acute hepatitis proven due to HAV (~ALT 2000 U/L, elevated bilirubin and INR, HAV IgM positive and detectable HAV RNA PCR). At 4months post-DDKT, she has improved but has persistent transaminitis (~100). Patient B had low level transaminitis (~ALT 100 U/L) at 4wk post-DDKT but remained asymptomatic, until 3months post-DDKT when he developed symptomatic acute hepatitis (pruritus, ~ALT 1200 U/L), work-up also demonstrated acute HAV. His symptoms resolved and liver enzymes have since normalized. The donor had normal liver enzymes at procurement but there was an HAV outbreak in the procurement area. Donor transmission was confirmed by HAV genotype analysis.

*Results: HAV human transmitted disease ( via fecal-oral route) causes acute hepatitis, which is usually self-limited but rarely can be fulminant or persistent. Despite availability of an effective vaccine, there has been a recent sharp increase in the US (140% from 2011-2017), with ~3,500 cases of HAV in 2017. Due to the illness’ transient nature and low incidence, routine screening for HAV is not conducted for blood, organ, or tissue donors, and only 1 prior case of SOT-related transmission has been reported. Our cases highlight the high susceptibility of SOT recipients to HAV with significant but delayed disease, longer incubation period, and a more subacute symptomatic presentation. Rapid communication between CDC, OPTN and transplant center was critical in identifying and monitoring these cases. While universal donor screening is not warranted, additional screening should be considered for local areas of known outbreak of HAV. Hepatitis A vaccination of potential transplant recipients is the mainstay for prevention. Both recipients did not remember about their hepatitis A vaccine and they also did not have protective HAV IgG and could have benefited with vaccination.

*Conclusions: The SOT recipients are high risk of symptomatic disease with transmission and pre-transplant vaccinations should be universally employed. While HAV is not a widespread public health disease in US, the incidence is rising and enhanced screening for donors in HAV outbreak area should be considered.

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