TABLE 1.
Demographic characteristics and clinical course of the LKR and RKR with donor-derived HAV infection
| LKR, index case | RKR | |
|---|---|---|
| Demographics | ||
| Age (rounded by decadea) | 50 | 60 |
| Sex | F | M |
| Medical history | ||
| Transplant indication | ESRD secondary to hypertensive nephrosclerosis | ESRD secondary to hypertension and type 2 diabetes mellitus |
| Previous hepatitis A vaccine? | Did not recall vaccination | Unknown |
| Laboratory data | ||
| HAV anti-IgM | Positive (+) at day 50 posttransplant | Negative (−) at day 63 posttransplant, positive (+) at day 82 posttransplant |
| HAV anti-IgG | Negative (−) at day 50 posttransplant | Negative (−) at day 63 posttransplant, positive (+) at day 82 posttransplant |
| HAV RNA tests (Table S1, SDC, http://links.lww.com/TXD/A549) | Estimated HAV loads from serum and stool were 7.6 and 6.5 log10 IU/mL at 99 d posttransplant. Periodic tests of serum and/or stool remained positive through day 189 when values had decreased to 1.69 and 1.26 log10 IU/mL. The subsequent specimen collected at day 383 was negative for HAV RNA. | Estimated HAV load from serum was 7.62 log10 IU/mL at 85 d posttransplant. Periodic tests of serum and/or stool remained positive through day 176 when values had decreased to 1.17 log10 IU/mL in serum. The subsequent specimen collected at day 198 was negative for HAV RNA |
| Other pathogen testing | Negative for HBsAg, HCV NAAT at day 61 posttransplant.Negative for CMV NAAT at 61 d posttransplant | Negative for HBsAg and HCV antibody tests at day 82 posttransplant.Positive CMV serum viral load of 79 IU/mL at day 82 posttransplant |
| Liver enzymes, including AST and ALT, ALP, and Tbili | AST/ALT:Normal until 19 d posttransplant when began steadily increasing (Figure 1A). ALT and AST levels peaked at 1960 and 1056 U/L, respectively (Figure 1A) at day 61 posttransplant and trended down afterward.Tbili:Elevated at day 61 posttransplant and trended down afterward (Figure 1B).ALP: remained normalSee Figure 1 | AST/ALT:Elevated 26 d posttransplant and remained mildly elevated in subsequent months (Figure 2A). ALT and AST levels peaked at day 82 posttransplant at 1209 and 1049 U/L, respectively, and trended down afterward.Tbili:Elevated at 7.6 mg/dL day 82 posttransplant, peaked at 14.3 mg/dL on day 89 and trended down afterward (Figure 2B).ALP: elevated at 115 U/L at day 82See Figure 2 |
| Other testing | ||
| Imaging studies | Liver ultrasound normal at 44 d posttransplantMagnetic resonance cholangiopancreatography normal at 61 d posttransplant | Liver ultrasound normal at 82 d posttransplant |
| Clinical history | ||
| HAV risk factorsb | None reported | None reported |
| Hospitalization history posttransplant | Hospitalization for kidney transplant, 4 d, uneventfulHospitalization from day 61 to 63 posttransplant for weight loss and ongoing intermittent vomiting; without diarrhea, abdominal pain, fever, jaundice, or hepatomegaly | Hospitalization for kidney transplant, 3 d, uneventful Hospitalization from day 82 to 87 posttransplant for progressively worsening malaise and acute liver injury |
| Symptom history posttransplant | Developed new onset nausea/vomiting 19 d posttransplantDeveloped diarrhea 19 d posttransplant, resolved after changing from myocyphenolate mofetil to mycophenolic acidHad experienced 20 lb weight loss by day 61 posttransplant | Developed malaise and anorexia posttransplant Developed vomiting, diarrhea, and a 40-pound weight loss by day 82 posttransplant hospitalization |
| Immunosuppressive and prophylaxis medication regimen posttransplant | Induction immunosuppression with methylprednisolone alone; antithymocyte globulin held as absolute lymphocyte count was 0 at the time of transplant.Maintenance medications included tacrolimus, prednisone; MPA was held due to leukopenia starting 61 d posttransplant. Valganciclovir for CMV prophylaxis.MPA was held when diagnosed with acute hepatitis A but resumed once symptoms improved and transaminases normalized | Induction immunosuppression with methylprednisolone and antithymocyte globulin.Maintenance medications included tacrolimus, MPA, and prednisone. Valganciclovir was held due to pancytopenia.MPA was held when diagnosed with acute hepatitis A but resumed once symptoms improved and transaminases normalized |
aAge rounded to the nearest decade for deidentification purposes.
bHAV infection risk factors in the United States currently include contact with someone with HAV, travel to endemic regions, exposure to contaminated food, experiencing homelessness or unstable housing, men who have sex with men, illicit drug use, recent incarceration.
ALP, alkaline phosphatase; ALT, alanine aminotransferase; anti-IgG, IgG antibody; anti-IgM, IgM antibody; AST, aspartate aminotransferase; CMV, cytomegalovirus; ESRD, end-stage renal disease; HAV, hepatitis A virus; HBsAg, hepatitis B surface antigen; HCV, hepatitis C virus; LKR, left kidney recipient; MPA, mycophenolic acid; NAAT, nucleic acid amplification testing; RKR, right kidney recipient; Tbili, total bilirubin.