Reactivation of occult hepatitis B virus infection in a renal transplant recipient

Renal transplantation (RT) is the first-choice treatment for patients with end-stage renal disease [1]. Following RT, rejection is prevented by drugs or biological agents [2, 3]. In these immunosuppressed patients, hepatitis B virus reactivation (HBVr) is not uncommon, and it may lead to severe acute hepatitis, fulminant liver failure, and death [4‐6]. Occult HBV infection (OBI), defined as the detection of HBV-DNA in the liver and/or serum in HBsAg-negative individuals, has attracted considerable attention in recent years [7, 8].

Here, we report a case of HBVr manifesting as OBI in a renal transplant recipient despite a pre-existing protective anti-HBs antibody titre. A rare HBV serological spectrum was determined, with further analysis showing that the activated virus was an escape mutant.

A 71-year-old male patient previously diagnosed with congenital polycystic kidney disease and hypertensive nephrosclerosis had been vaccinated against HBV. He underwent RT on November 27, 2019. Pre-transplant HBV serological analysis showed that he was positive for anti-HBc and anti-HBs (146.91 mIU/ml). In December 2020, HBV-DNA was detected serum, although HBsAg and HBeAg were negative in serum. Two weeks later, the HBV viral load increased to 74.5 IU/ml, and HBeAg became weakly positive. In February 2021, he received nucleoside antiviral drugs (tenofovir alafenamide, TAF) once his HBV viral load (2440 IU/ml) exceeded 2000 IU/ml, and once he became clearly HBeAg positive. One month after antiviral therapy, serum HBV-DNA became undetectable, and HBeAg showed seroconversion (HBeAg became negative and HBeAb became positive). Antiviral drugs were discontinued after one course of treatment (3 months). At the latest follow-up, HBV-DNA was not detected. The serum level of alanine aminotransferase was always normal. Due to the patient's older age, further HBV virus detection in the patient’s liver tissue and pathological biopsy analysis were not performed.

HBV infection with detectable HBV-DNA but HBsAg negativity was found in a male patient during the first year after RT. The HBV DNA viral load increased from 68.6 to 2440 IU/ml, and HBeAg became obviously positive within 2 months, consistent with reactivation and occult infection [5, 7]. Since vaccination does not lead to the production of anti-HBc antibodies [9], pre-transplant anti-HBc positivity indicates a history of HBV exposure and a long persistence of HBV covalently closed circular DNA in liver cells [10, 11]. As the patient had been taking tacrolimus (FK506) to suppress kidney rejection, immunosuppression-induced reactivation with resolved HBV infection was the most likely diagnosis.

In individuals who have undergone vaccination, anti-HBs antibody concentrations > 100 mIU/ml imply a high level of protection [12]. Previous studies showed that a progressive decline in anti-HBs antibody titres is a predictor of HBVr [13, 14]. However, this was not supported by the HBV serological data in our patient, in whom HBVr occurred in the presence of a high pre-existing anti-HBs antibody titre, which gradually increased to 951.36 mIU/ml after reactivation. Wang et al. [15] reported increases in the post-transplant anti-HBs titres in HBsAg-negative renal transplant recipients who received a kidney from an HBsAg-positive donor. The authors speculated that HBsAg stimulation was similar to HBV “vaccination”. A subsequent neutralisation analysis showed good reactivity of anti-HBs antibodies to the rHBsAg subtypes adw and adr but poor reactivity to the ayw subtype. These findings demonstrate that despite the presence of a high titre and specific anti-HBs antibodies in our patient, HBV reactivation and replication were not inhibited.

To elucidate the underlying mechanism of the OBI, we investigated the genetic features of the HBV strain. An analysis of the complete genome sequence revealed that the virus was genotype C1, serological subtype adw2 [16]. Further analysis of HBsAg amino acids identified 16 substitutions. Substitutions I126N and P142L were located in the “a” determinant region (amino acids 124–147, major target of neutralising antibodies). Both are considered typical mutations associated with the ability of HBsAg to escape detection and vaccine efficacy [17, 18]. Additionally, amino acid substitution at positions Y100C, Q101H, T118K, V159A, and R160K (located in the major hydrophilic region, close to the “a” determinant) may also alter HBsAg antigenicity [19, 20]. HBV strains carrying these HBsAg mutations may escape recognition by diagnostic and protective antibodies, resulting in virus reactivation and diagnostic failure (negative for HBsAg).

However, several questions remain to be considered. First, why were HBV mutations present? Second, why was there no decrease, but rather an increase in anti-HBs antibody levels, after HBVr? The literature suggests that HBV-specific T cells are the main effectors that eliminate infected cells or inhibit viral replication [21, 22], such that treatment with the T-cell inhibitor tacrolimus (FK506) to prevent transplant rejection is associated with a high risk of HBVr [3, 23]. The mutated HBV may reflect selection for immune escape in this vaccinated transplant recipient and thus its efficacy in reactivation [5]. However, wild-type HBV strains that stimulate the proliferation and differentiation of HBV-specific memory B cells, and in turn the production of anti-HBs antibodies, no doubt persisted [16, 24]. Since anti-HBs antibodies are not directed against viral mutants, they have no protective activity.

This case demonstrates the potential reactivation of an HBV escape mutant, resulting in occult infection. It thus provides insight into the persistence of HBV protective immunity after variant infection. Moreover, it is a reminder of the importance of HBV DNA detection in monitoring immunosuppressive patients with a history of HBV infection. Early recognition of virological replication and initiation of antiviral therapy can prevent further liver damage.