Transmission or 'occult' hepatitis B infection after living-related liver transplantation

A 22-year-old female with origin unknown liver cirrhosis in the absence of serological markers for hepatitis B (HBV) except for HBV-DNA developed fulminant hepatitis with HBV after liver transplantation. The donor was her father with Gilbert’s syndrome who showed anti-HBs and low titer anti-HBc positive. Severe hepatitis developed in the grafted liver due to HBV at 11 months postoperatively. HBsAg and HBeAg became positive, while anti-HBs, anti-HBe, anti-HBc, and hepatitis C were negative. After hepatitis B infection was confirmed by a liver biopsy, treatment with HB immunoglobulin and prostaglandin E1 were initiated. Despite intensive-care support including frequent plasma exchange and continuous hemofiltration, the patient died at 16 months postoperatively. Pre-transplant serum HBV-DNA was positive in the recipient but negative in the donor, while immunopathologic studies for HBsAg and HBV-DNA were negative in the liver of both the recipient and donor. Therefore, acquisition of HBV in the recipient would be due to occult pre-transplant infection. In conclusion, the pre-transplant evaluation of HBV-DNA in the liver tissue and serum should be examined when liver transplantation is attempted in patients with origin unknown liver cirrhosis.