Failure of hepatitis B surface antibody to protect acute fulminating hepatitis in a renal transplant recipient.

A 58-year-old man who had a living-related kidney transplantation (KT) 13 years ago and had received a double-dosage course of hepatitis B virus (HBV) vaccination prior to KT developed acute liver failure. An exhaustive work-up for the cause of acute liver failure revealed that HBsAg was negative but anti-HBs and anti-HBcAbs were positive. HBV DNA was 535,000 copies/ml. The strongly positive staining of HBsAg and HBcAg of liver biopsy was shown by immunohistochemistry examination. HBV harboring surface mutant of hepatitis B surface gene was thought to be the cause of acute fulminant hepatitis despite the presence of protective immunity to wild-type HBV. The patient expired from acute liver failure even though an antiviral drug was started promptly. This is the first case report of liver biopsy suggestive of acute fulminating HBV that developed in a long-term kidney recipient despite the presence of high anti-HBsAb titer.