US sees uptick in ‘unexpected’ HBV infection in liver transplant recipients
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There was a recent increase in “unexpected” hepatitis B virus infections among liver transplant recipients who received organs from donors who tested negative, according to findings published in MMWR.
Most of the donors were positive for hepatitis C virus and had a history of injection drug use, researchers reported.
“Recipients with signs or symptoms of liver injury after transplantation should be tested for viral hepatitis, even if previous HBV or hepatitis C testing was negative,” Danae Bixler, MD, from the CDC’s Division of Viral Hepatitis, and colleagues wrote. “More broadly, providers caring for recipients of organs from donors who recently injected drugs or are HCV seropositive should maintain awareness of infectious complications of drug use and monitor recipients accordingly.”
Bixler and colleagues examined 20 reports between 2014 and 2019 of HBV infection among transplant recipients who received livers from donors with no evidence of past or current HBV infection. They reviewed laboratory and medical record data for each recipient.
They found that 14 of the 20 cases were detected in 2019 alone, a median of 38 weeks following transplantation. Of the 14 donors, 13 tested positive for HCV and had a history of injection drug use within a year of their death, a positive toxicology result or both.
The researchers did not find behavioral risks or health care-associated HBV outbreaks for any reported cases. HBV vaccination status was not available for most recipients.
“HBV infection among transplant recipients can occur from reactivation of previous HBV infection, primary infection after transplantation, or donor-derived transmission,” the authors wrote. “This report provides evidence that transmission of HBV from donors occurred despite negative organ donor HBV DNA, [hepatitis B surface antigen], and total anti-[hemoglobin C] results before organ procurement.”
Perspective
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This report provides a continued wake-up call to transplant professionals that there are limitations in infectious disease screening at the time of organ donations, even with molecular testing. Among the infectious diseases screened, HBV is among the most challenging because HBV DNA can be present or remain archived in the liver, even if there is no detectable viremia in the blood at screening at the time of organ procurement. Thus, it makes sense that unexpected HBV transmissions occur predominantly in liver transplant recipients. It is also important to note that most of these donors are people who inject drugs and who may have had antecedent risk behaviors, leading to early infection escaping screening at the time of donation.
Risk can be mitigated by following the U.S. Public Health Service guidelines to screen recipients for HIV, HBV and HCV early after transplant and to repeat HBV screening of (particularly liver) recipients at 1 year after transplant. This paper adds more specificity in screening: unexpected HBV transmissions were predominantly represented in donors infected with HCV and among donors who injected drugs, and they primarily occurred within 1 year following transplantation. As our donor pool continues to be supplemented with organs from drug overdose deaths, these become important and timely considerations for all transplant centers to consider. At the end of the day, these are a handful of occurrences from about 8,000 liver transplants per year in the United States. Indeed, organ transplantation continues to be a very safe proposition with robust infectious disease screening at donation, especially given the substantially higher mortality of advanced liver and other organ disease in the absence of transplantation.
References:
Jones JM, et al. MMWR Recomm Rep. 2020;doi:10.15585/mmwr.rr6904a1.
Theodoropoulos NM, et al. Transpl Infect Dis. 2021;doi:10.1111/tid.13458.
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