Occurrence and management of hepatitis B virus reactivation following kidney transplantation.

A 28-year-old woman was kidney transplanted. She had an inapparent hepatitis B virus (HBV) infection 2 years previously. At the time of transplantation she was hepatitis B surface antigen (HBsAg) negative, anti-HBs, anti-HBc, anti-HBe and anti-HCV antibody positive and her transaminase activities were within the normal range. The donor of the kidney allograft was HBV negative. Twelve weeks after transplantation a life-threatening liver failure occurred with a rapid rise of alanine aminotransferase (ALT) to 1427 U/l and a decrease of the prothrombin time to 25% of normal value. Anti-HBs had become negative, anti-HBc and anti-HBe titers had decreased. HBsAg became positive, associated with a HBV DNA of 3 x 10(8) genome equivalents/ml. Azathioprine and prednisone were withdrawn and foscarnet therapy was started. This therapy led to a decrease of ALT activity associated with an elimination of HBsAg and HBV DNA. Eight months after transplantation liver function tests were within the normal range. Graft rejection did not occur despite low or intermittent cessation of immunosuppressive therapy.