Hepatitis B Virus Mutant Infections in Hemodialysis Patients: A Case Series

• Type of Material: Article
• Authors: Ibironke Apata, Emory University; Duc B. Nguyen, Centers for Disease Control and Prevention; Yury Khudyakov, Centers for Disease Control and Prevention; Tonya Mixson-Hayden, Centers for Disease Control and Prevention; Jon Rosenberg, Healthcare-Associated Infections Program; Matt Zahn, Orange County Public Health Laboratory; Jane Greenko, New York State Department of Health; Ernest Clement, New York State Department of Health; Allison E. Portney, New Jersey Department of Health and Senior Services; Prathit A. Kulkarni, Centers for Disease Control and Prevention; Maura Comer, Florida Department of Health; Eleanor Adams, New York State Department of Health; Saleem Kamili, Centers for Disease Control and Prevention; Priti Patel, Emory University; Anne C. Moorman, Centers for Disease Control and Prevention
• Language: English
• Date: 2019-11-01
• Publisher: Elsevier
• Publication Version: Final Published Version
• Copyright Statement: © 2019 Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.xkme.2019.07.011
• Title of Journal or Parent Work: Kidney Medicine
• Volume: 1
• Issue: 6
• Start Page: 347
• End Page: 353
• Grant/Funding Information: None.
• Keywords: hepatitis B surface antigen mutation; hemodialysis; hepatitis B virus infection; hepatitis B surface antigen seroconversion; hepatitis B virus mutation
• Research Categories: Health Sciences, Public Health; Health Sciences, Immunology; Health Sciences, Epidemiology

Abstract

Rationale & Objective Hepatitis B virus (HBV) transmission in hemodialysis units has become a rare event since implementation of hemodialysis-specific infection control guidelines: performing hemodialysis for hepatitis B surface antigen (HBsAg)-positive patients in an HBV isolation room, vaccinating HBV-susceptible (HBV surface antibody and HBsAg negative) patients, and monthly HBsAg testing in HBV-susceptible patients. Mutations in HBsAg can result in false-negative HBsAg results, leading to failure to identify HBsAg seroconversion from negative to positive. We describe 4 unique cases of HBsAg seroconversion caused by mutant HBV infection or reactivation in hemodialysis patients. Study Design Following identification of a possible HBsAg seroconversion and mutant HBV infection, public health investigations were launched to conduct further HBV testing of case patients and potentially exposed patients. A case patient was defined as a hemodialysis patient with suspected mutant HBV infection because of false-negative HBsAg testing results. Confirmed case patients had HBV DNA sequences demonstrating S-gene mutations. Setting & Participants Case patients and patients potentially exposed to the case patient in the respective hemodialysis units in multiple US states. Results 4 cases of mutant HBV infection in hemodialysis patients were identified; 3 cases were confirmed using molecular sequencing. Failure of some HBsAg testing platforms to detect HBV mutations led to delays in applying HBV isolation procedures. Testing of potentially exposed patients did not identify secondary transmissions. Limitations Lack of access to information on past HBsAg testing platforms and results led to challenges in ascertaining when HBsAg seroconversion occurred and identifying and testing all potentially exposed patients. Conclusions Mutant HBV infections should be suspected in patients who test HBsAg negative and concurrently test positive for HBV DNA at high levels. Dialysis providers should consider using HBsAg assays that can also detect mutant HBV strains for routine HBV testing.