Background: Donor-derived hepatitis A virus (HAV) transmission is rarely reported following kidney transplantation. We describe two patients who contracted acute HAV following deceased-donor kidney transplant (DDKT) from a shared donor.

Methods: The donor was a 36 year old woman who died of complications of hepatic encephalopathy.  Her history included cirrhosis due to chronic hepatitis C virus (HCV) infection, injection drug use, and alcohol dependence. KDPI was 83%. Donor testing revealed a positive anti-HCV IgG, negative HCV nucleic acid testing, and a positive anti-HAV IgM. The anti-HAV IgM was a clinical test and not included in the donor summary.  A 52-year-old man (patient A) and a 48-year-old man (patient B) both underwent DDKT from this donor. Both patients received alemtuzumab induction and immunosuppression with tacrolimus, mycophenolate, and prednisone. Patient A developed an acute elevation in liver transaminases at 3 months post-transplant, accompanied by nausea, weakness, and malaise requiring hospitalization.  Transaminases peaked with alanine transferase (ALT) 893 IU/L and total bilirubin (TB) 2.4 mg/dL.  Liver biopsy showed portal and lobular hepatitis with plasma cell-rich inflammation. Serologic testing revealed a positive anti-HAV IgM, despite pre-transplant testing with anti-HAV IgG positivity consistent with prior immunity. ALT and TB normalized by 5 months post-transplant with supportive care. Patient B had an asymptomatic ALT elevation of 99 IU/L at 3 months post-transplant.  He presented to clinic 2 weeks later with jaundice; testing showed TB 6.9 mg/dL and ALT 149 IU/L. Anti-HAV IgM was newly positive; anti-HAV IgM and IgG were negative pre-transplant. His transaminases gradually normalized with supportive care.

Results: This is the second known case of donor-derived transmission of HAV to dual recipients following DDKT. HAV is normally transmitted by the fecal-oral route after contact with infected individuals or with contaminated water or food. Although hepatitis A is usually self-limited, fulminant hepatitis is an uncommon life-threatening complication. HAV is less common in the United States than in developing countries, but outbreaks occur in areas with low vaccination rates. Hepatitis A vaccination is highly protective and is recommended for children and high-risk adults, including travelers to endemic areas and individuals with chronic liver disease. The American Society of Transplantation recommends HAV vaccination for transplant candidates.

Conclusions: Donor-derived HAV infection is rare, but may be under-diagnosed.  While active HAV is typically a self-limited disease, transplant recipients may face greater risks.  Vaccination reduces the risk of infection and should be considered prior to transplant in non-immune candidates. In transplant recipients presenting with new transaminase elevations, HAV infection should be included in the differential, regardless of pre-transplant immunity.