Renal transplantation from hepatitis B surface antigen (HBsAg)‐positive donors to HBsAg‐negative recipients: a case of post‐transplant fulminant hepatitis associated with an extensively mutated hepatitis B virus strain and review of the current literature

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Abstract
Purpose: The purpose of this study was to present a fatal case of fulminant hepatitis B (FHB) that developed in a renal transplant recipient, immunized against hepatitis B, 1 year post transplantation.Methods: Polymerase chain reaction amplification and full genome sequencing were performed to investigate whether specific mutations were associated with hepatitis B virus (HBV) transmission and FHB.Results: Molecular analysis revealed multiple mutations in various open reading frames of HBV, the most important being the G145R escape mutation and a frameshift mutation–insertion (1838insA) within the pre‐C/C reading frame.Conclusions: Our results highlight the possibility of developing FHB, despite previous immunization against HBV or administration of hyperimmune gammaglobulin, because of the selection of escape virus mutants. The current literature and guidelines regarding renal transplantation from hepatitis B surface antigen (HBsAg)‐positive to HBsAg‐negative patients were also reviewed.

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