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Ready to upload
Record number:
1712
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
De novo acquisition of HBV from donors with HBsAg negative, anti-core positive serological profile (past HBV infection) is well described in liver transplantation. Frequency of transmission varies, depending on various parameters, and can be high without intervention such as anti-viral prophylaxis. Refer to local guidance for correct recipient management.
Time to detection:
An accurate time to HBV reactivation in this case cannot be determined as there was no monitoring for HBV markers. Positive tests for HBsAg and HBeAg were incidental findings at one-year postransplant.
Alerting signals, symptoms, evidence of occurrence:
The liver donor was positive for anti-HBc and anti-HBs and negative for HBsAg and HBV DNA at a detection limit of 12IU/ml of plasma.The donated liver showed macrosteatosis without active hepatitis or cirrhosis and was negative for HBV DNA, HBsAg and HBV delta antigen. At the time of transplant the recipient did not have anti-HBc, anti-HBsAg, HBsAg, HBV DNA or abnormal liver enzyme levels in blood. The recipient did not receive HBV prophylaxis nor was monitored for HBV after OLT.
On PTD 11 anti-HBs (52.9IU/ml) and anti-HAV IgG were detected but these were transitory, passively acquired from transfusions (including 13 units of FFP). At one year post-transplant the recipient was tested as part of a cohort study and found to be positive for HBsAg, HBeAg and HBV DNA, all at high levels, indicating high level of viral replication. Anti-HBc was negative and remained negative; liver enzyme levels were normal. Entecavir treatment and increase in daily dosage (0.5 to 1mg) led to a 5 log reduction in HBV DNA load but it continues to be detected at around 3000IU/ml.
Demonstration of imputability or root cause:
A look back on the blood components administered to the liver recipient was carried out, with no evidence of transfusion transmitted infection. Other sources of HBV infection were deemed extremely unlikely and the authors consider the liver graft as the most probable source of HBV.
Imputability grade:
2 Probable
Groups audience:
Keywords:
Reference attachment:
Suggest references:
Reactivation of hepatitis B virus with mutated hepatitis B surface antigen in a liver transplant recipient receiving a graft from an antibody to hepatitis B surface antigen- and antibody to hepatitis B core antigen-positive donor. Blaich A et al. Transfusion. 52(9):1999-2006, 2012 Sep.
Expert comments for publication:
This is a description of a very complex set of events, highlighting very different, but important issues. Readers are encouraged to read the whole paper as well as related cited references. It stresses the importance of correctly assigning the serological status and realising the effect of blood components and products on the correct interpretation of results; use of recipient historical results is not appropriate. There are guidelines on the management of recipients of solid organ grafts from anti-HBcore positive donors (e.g AASDL, EASL, BTS).