Case Presentation: A 72 year old male with a history of end stage renal disease and chronic positive hepatitis B core antibody since 2020 presented with worsening abdominal pain while undergoing hemodialysis. He was not on any immunosuppressive medications at home. On admission, his vitals were normal. Physical exam revealed scleral icterus and right upper quadrant tenderness. Murphy’s sign was negative. Laboratory workup showed AST of 1053IU/L (12-52 IU/L) and ALT of 658IU/L (7-49 IU/L). His alkaline phosphatase was 255IU/L (39-117 IU/L), GGT was 412IU/L (12-85 IU/L), total bilirubin was 6.8mg/dl (0.1-1.2mg/dl) and direct bilirubin was 4.8 mg/dl (0-0.4mg/dl). Iron studies showed a ferritin level of 31,145ng/ml (22-275 ng/ml), transferrin of 71mg/dl (168-351mg/dl) and iron level of 114ug/dl (37-141ug/dl). MRI of the abdomen was done that showed non specific pericholecystic fluid and small volume ascites. On day 2, his hepatitis B surface Ag (HBsAg) was positive. His hepatitis Be Antigen was positive and his HBV viral load was 49,300,000 IU/L. He was started on entecavir 1mg once weekly. His liver function tests improved although they plateaued after a few days. Subsequently, the patient became encephalopathic and developed hypoglycemia along with bradycardia. He was determined to not be a candidate for liver transplantation given his active infection. Following discussion with the patient’s family, it was decided to transition the patient to comfort focused care.s
Discussion: Patients with end stage renal disease and prior Hepatitis B virus (HBV) infection represent a challenge for clinicians. HBV reactivation leading to an immune -active state may happen at any time, and pose a higher rate of morbidity and mortality than in the general population. Reactivation of hepatitis B following immune suppression is a known entity. However, the reason for Hepatitis B reactivation in our patient remains unclear, especially since he tested negative for HBsAg and HBV DNA three months ago.In general, dialysis patients should be vaccinated against HBV infection and have an annual test regarding their hepatitis B antibody (anti-HBs) titer. The goal is to maintain a titer >10mIU/mL to ensure adequate protection. Renal patients may need booster doses and in some cases second full vaccination series to achieve this goal. Those whose have low titers after a second series are deemed non-responders. His last hepatitis B vaccination was a year ago as his hepatitis B antibody titer was low. It is unclear if he received any booster doses. Antiviral treatment is recommended for patients who are hepatitis B surface antigen positive and show signs of active liver disease, with elevated serum HBV DNA levels, regardless of whether a liver biopsy has been performed. Entecavir is typically preferred due to its efficacy and safety profile. Patients on the transplant list should be monitored every 6-12 months with HBV-DNA and transaminase levels.
Conclusions: Physicians should closely monitor patients on dialysis with a history of HBV infection or positive core HBV antibodies through regular liver function tests and HBsAg testing to minimize the risk of reactivation and widespread infection. Those with sub-optimal antibody titers should be given booster doses to achieve levels >10mIU/mL. Non-responders need close monitoring as indicated and hepatocellular cancer surveillance. In addition, physicians should be particularly alert for the possibility of acute viral hepatitis in patients exhibiting extreme hyperferritinemia and transaminitis.