Observational Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 14, 2018; 24(6): 752-762
Published online Feb 14, 2018. doi: 10.3748/wjg.v24.i6.752
High prevalence of hepatitis B-antibody loss and a case report of de novo hepatitis B virus infection in a child after living-donor liver transplantation
Palittiya Sintusek, Nawarat Posuwan, Piyaporn Wanawongsawad, Suttiruk Jitraruch, Yong Poovorawan, Voranush Chongsrisawat
Palittiya Sintusek, Suttiruk Jitraruch, Yong Poovorawan, Voranush Chongsrisawat, Division of Gastroenterology and Hepatology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
Nawarat Posuwan, Yong Poovorawan, Center of Excellence in Clinical Virology, Chulalongkorn University, Bangkok10330, Thailand
Piyaporn Wanawongsawad, Excellence Center of Organ Transplantation, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
Author contributions: Sintusek P, Poovorawan Y and Chongsrisawat V contributed to study conception and design; Sintusek P and Wanawongsawad P contributed to data acquisition; Sintusek P and Posuwan N were responsible for data analysis and interpretation; Sintusek P wrote the article; Sintusek P, Jitraruch S, Poovorawan Y and Chongsrisawat V contributed to editing, reviewing and final approval of the article.
Supported by the Development of New Faculty Staff, Ratchadaphiseksomphot Endowment Fund to Sintusek P; The Special Task Force for Activating Research in Immune Response in Children with Chronic Liver Diseases and Children after Liver Transplantation, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand to Sintusek P; the Research Chair Grant from the National Science and Technology Development Agency, No. P-15-50004 to Poovorawan Y; and The Center of Excellence in Clinical Virology, Chulalongkorn Unversity and King Chulalongkorn Memorial Hospital, No. GCE 5900930-005 to Poovorawan Y.
Institutional review board statement: The study was reviewed and approved by the Ethics Committee, Faculty of Medicine, Chulalongkorn University (IRB number 614/60).
Informed consent statement: All study participants, or their legal guardian, provided verbal consent prior to study enrolment.
Conflict-of-interest statement: None of the authors has any potential conflict to declare.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at voranush.c@chula.ac.th. Consent was not obtained but the presented data are anonymized and the risk of identification is low.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Voranush Chongsrisawat, MD, Associated Professor, Chief, Division of Gastroenterology and Hepatology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand. voranush.c@chula.ac.th
Telephone: +66-2-2564951 Fax: +66-2-2564911
Received: December 5, 2017
Peer-review started: December 6, 2017
First decision: December 21, 2017
Revised: January 5, 2018
Accepted: January 20, 2018
Article in press: January 20, 2018
Published online: February 14, 2018
Processing time: 62 Days and 8.8 Hours
Abstract
AIM

To assess the seroprevalence of hepatitis B virus (HBV) immunity among previously vaccinated pediatric liver transplant recipients and present a case report of de novo hepatitis B infection after liver transplantation.

METHODS

This study focused on children with chronic liver diseases who received primary hepatitis B immunization and had a complete dataset of anti-HBs before and after liver transplantation between May 2001 and June 2017. Medical records were retrospectively reviewed for potential factors relating to HBV immunity loss.

RESULTS

In total, 50 children were recruited. The mean time from liver transplantation to anti-HBs testing was 2.53 ± 2.11 years. The mean anti-HBs levels before and after liver transplantation were 584.41 ± 415.45 and 58.56 ± 6.40 IU/L, respectively. The rate of non-immunity (anti-HBs < 10 IU/L) in the participants was 46% (n = 26) at one year, 57% (n = 7) at two years and 82% (n = 17) at > three years following liver transplantation. The potential factors relating to HBV immunity loss after liver transplantation were identified as anti-HBs (P = 0.002), serum albumin (P = 0.04), total bilirubin (P = 0.001) and direct bilirubin (P = 0.003) before liver transplantation. A five-year-old boy with biliary cirrhosis received 4 doses of HBV vaccine with an anti-HBs titer of > 1000 IU/L and underwent liver transplantation; his anti-HBc-negative father was the donor. After liver transplantation, the boy had stenosis of the hepatic artery up to the inferior vena cava anastomosis and underwent venoplasty three times. He also received subcutaneous injections of enoxaparin for 5 mo and 20 transfusions of blood components. Three years and ten months after the liver transplantation, transaminitis was detected with positive tests for HBsAg, HBeAg, and anti-HBc (2169.61, 1706 and 8.45, respectively; cutoff value: < 1.00) and an HBV viral load of 33212320 IU/mL.

CONCLUSION

The present study showed that loss of hepatitis B immunity after liver transplantation is unexpectedly common. In our case report, despite high levels of anti-HBs prior to transplantation, infection occurred at a time when, unfortunately, the child had lost immunity to hepatitis B after liver transplantation.

Keywords: Hepatitis B vaccine; Liver transplantation; De novo hepatitis B infection; Anti-HBs antibody; Immunity

Core tip: Despite the completion of hepatitis B vaccination, loss of hepatitis B immunity in children after liver transplantation is common and we encountered a case of de novo hepatitis B virus (HBV) infection following liver transplantation. Serum anti-HBs, albumin, total bilirubin, and direct bilirubin prior to liver transplantation were identified as potential factors related to HBV immunity loss after liver transplantation. A booster dose of hepatitis B vaccine and raising serum albumin to normal levels could delay the rapid loss of HBV immunity after liver transplantation but may not prevent de novo hepatitis B. Consequently, strategies are required to maintain anti-HBs antibody above the protective level after liver transplantation. Regular assessment of anti-HBs after liver transplantation should also be considered along with revaccination to guarantee long-term protection from HBV infection.