Abstract: TH-PO906

Hepatitis B Prevention in Dialysis – Needs Reconsideration

Session Information

  • Dialysis: Infection
    November 02, 2017 | Location: Hall H, Morial Convention Center
    Abstract Time: 10:00 AM - 10:00 AM

Category: Dialysis

  • 610 Dialysis: Infection

Author

  • Agarwal, Sonalika, Hnery Ford Hospital, Detroit, Michigan, United States
Background

Hepatitis B virus (HBV) infection is a significant cause of morbidity in end stage renal disease (ESRD) patients undergoing hemodialysis (HD). A significant reduction in the incidence of HBV has occurred by segregating patients with the disease from those who are at risk for contracting it. We report a case of a patient on HD who developed seroconversion to hepatitis B surface antigen (HBsAg) positivity with viremia despite presumed natural immunity to HBV.

Methods

Our patient is a xx-year-old female who was started on HD in 2012. At that time, her serum HBsAg was negative, hepatitis core antibody (HBcAb) was positive and hepatitis b surface antibody titer >150 mIU/ml implying a prior history of infection with natural immunity. She lacked risk factors for contracting the HBV infection and was dialyzed with the general population in our dialysis unit. Routine annual screening yielded a positive HBsAg despite having negative levels in the past; however, she maintained a high titer of HBsAb. Additional testing revealed a negative IgM HBcAb, positive HBeAb and normal transaminase levels reflecting the absence of a new infection. Given low-grade viremia (1,489 IU/ml), the decision was made to relocate her to a dedicated dialysis machine in the unit isolation area. Hepatology diagnosed her with a chronic inactivated form of hepatitis infection. A month later her repeat hepatitis panel showed seroconversion back to HBSAg negativity.

Conclusion

HBeAg negative patients with normal serum transaminases and low (<2000 IU/mL) or undetectable HBV DNA are considered to be in an inactive carrier state. According to Center for Disease Control (CDC) guidelines updated in 2016, patients who are HBsAg negative and HBsAb positive are not considered infectious. Annual HBsAb testing confirms that immunity is not lost in this population. The CDC does not recommend rechecking HBSAg on HD patients once antibody screen establishes immunity. This case highlights the importance of recognizing the chronic inactive hepatitis B infection state in HD patients. Given potential for transmission of infection during transient viremia, these patients should be isolated from the general population during HD. Although current guidelines do not recommend routine testing for HBsAg in HD patients with known immunity, addition of antigen testing to routine surveillance may be warranted to reduce the risk of HBV transmission in this population.