Hepatitis A Virus ( HAV ) Recurrence and De Novo Hepatitis A Acquired at Time of Liver Transplantation: Comparison of Graft HAV Infection and Viral Kinetics

Hepatitis A virus (HAV) infection is an uncommon indication for liver transplantation, and donor-derived or transfusion-associated HAV infection is rare. Data describing HAV recurrence or early acquisition following liver transplantation, particularly with longitudinal quantitative viral kinetics, are limited. We describe two liver transplant recipients with graft HAV infection occurring in different immunological contexts. One patient underwent emergency liver transplantation for HAV-related acute liver failure and subsequently developed recurrent HAV infection of the graft. The second patient underwent liver transplantation for paracetamol-induced acute liver failure and acquired HAV infection following peri-operative blood transfusion in the early post-transplant period. Serial qualitative and retrospective quantitative HAV ribonucleic acid (RNA) polymerase chain reaction (PCR) measurements were analysed alongside biochemical and clinical parameters. In the patient transplanted for fulminant HAV infection, serum HAV RNA declined rapidly after transplantation, consistent with removal of the infected native liver, followed by recurrent viraemia associated with graft hepatitis during the second and third post-transplant months, and with viral clearance by 4 months. In contrast, the transfusion-acquired HAV infection occurred in the setting of profound immunosuppression and absence of pre-existing immunity, resulting in a higher peak viral load, prolonged viraemia lasting over 9 months, and more severe graft hepatitis. Viral doubling times during viraemic expansion were similar in both cases but sustained high-level viraemia was observed only in the de novo infection. These cases provide novel insights into HAV viral kinetics following liver transplantation and highlight important differences between recurrent infection and newly acquired HAV infection in immunosuppressed recipients.