Abstract: SA-PO1155
Breaking the Rules of Immunity: A Rare Case of Hepatitis B Virus (HBV) Seroreversion and Reactivation After Kidney Transplantation
Session Information
- Transplantation: Clinical - Infectious Diseases
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Bavi, Santhoshi Rupa, Boston Medical Center, Boston, Massachusetts, United States
- Zaheer, Areej, Boston Medical Center, Boston, Massachusetts, United States
- Avissar, Uri, Boston Medical Center, Boston, Massachusetts, United States
- Ghai, Sandeep, Boston Medical Center, Boston, Massachusetts, United States
- Francis, Jean M., Boston Medical Center, Boston, Massachusetts, United States
Introduction
HBV reactivation after kidney transplant is uncommon in patients with strong pre-existing immunity and rarely involves complete serological reversal. We report a rare case of HBV reactivation after a kidney transplant, with loss of both surface antibody (anti-HBs) and core antibody (anti-HBc).
Case Description
A 74-year-old woman with ESKD due to hypertensive and diabetic nephrosclerosis underwent deceased donor kidney transplantation in September 2020. Pre-transplant serology (July 2020) showed resolved HBV infection (HBsAg negative, anti-HBc positive, anti-HBs >400 mIU/mL), and the donor was HBV-seronegative (HBsAg and anti-HBc negative). She received induction with anti-thymocyte globulin and methylprednisolone, followed by maintenance immunosuppression with tacrolimus, mycophenolic acid, and prednisone. Liver function remained normal through 2023, and HBV serology was not routinely monitored because the risk of reactivation was low.
In September 2023, she presented with acute hepatitis (AST 493 U/L, ALT 571 U/L, total bilirubin 1.9 mg/dL) and was found to have active HBV infection (HBsAg positive, HBeAg positive, HBV DNA >100,000,000 IU/mL), with loss of both anti-HBc and anti-HBs consistent with complete serological reversal. The dose of mycophenolic acid was lowered, and entecavir was initiated, leading to normalization of liver enzymes by September 2024 and suppression of HBV DNA to 24 IU/mL by December 2025, with reappearance of anti-HBc and low-level anti-HBs (22 mIU/mL) alongside persistent HBsAg. Kidney allograft function remained stable throughout.
Discussion
This case is unique for several reasons: (1) HBV reactivation occurred despite robust pre-transplant immunity (anti-HBs >400 mIU/mL), a threshold typically considered protective; (2) transient loss of anti-HBc suggests a profound failure of immune memory, likely immunosuppression-related; (3) concurrent presence of HBsAg and anti-HBs suggests an immune escape variant capable of persisting despite neutralizing antibodies.
This case argues for universal antiviral prophylaxis in kidney transplant recipients with prior HBV exposure, regardless of anti-HBs status. HBV DNA monitoring is essential for all immunosuppressed patients with prior exposure, and immune escape variants may justify indefinite antiviral therapy given the risk of persistent replication.