Hepatitis B virus reactivation in hepatitis B core antibody positive lung transplant recipients

Solid organ transplant recipients with resolved hepatitis B virus (HBV) infection are at risk for reactivation; however, most of the studies have focused on kidney transplant recipients and have short to intermediate term follow-up. Risk factors for reactivation are also uncertain, with some studies suggesting surface antibody (anti-HBs) may be protective.

This retrospective single-center study aimed to assess the risk of HBV reactivation (HBVr) in lung transplant recipients with prior HBV infection as well as the value of anti-HBs titers in predicting HBVr. Surface antigen (HBsAg) negative, core antibody (anti-hepatitis B core (HBc)) positive adult lung and heart-lung solid organ transplant recipients from 2005 to 2019 were included. The primary outcome was HBVr after transplant, defined as seroreversion to HBsAg positivity. The secondary outcome compared anti-HBs titers at transplant and at post-transplant month 12.

The cohort included 38 lung and heart-lung recipients with anti-HBc positive, HBsAg negative pretransplant serology. Reactivation occurred in 3 of 38 (8%) at 49, 69, and 94 months post transplant. Two (5% of cohort) subjects died as a consequence of HBVr. Two of the 3 HBVr patients had anti-HBs titers >10 IU/ml at transplant and 1 had anti-HBs >100 IU/ml at time of HBV reactivation. We did not find a statistically significant decrease in anti-HBs titers 1 year after transplant in subjects with baseline anti-HBs >10 IU/ml.

The prolonged time to reactivation highlights the lifelong risk. The 8% rate of reactivation and 5% mortality support a preferred strategy of indefinite HBV antiviral prophylaxis over monitoring in anti-HBc positive lung recipients.