Fibrosing cholestatic hepatitis in a hepatitis B surface antigen carrier after renal transplantation

A 45-year-old hepatitis B surface antigen carrier had an allograft kidney transplantation and maintenance immunosuppression with cyclosporin A and predniso-lone. Six months later, she experienced a rapidly progressive hepatic failure manifested by elevation of serum bilirubin level, prolongation of prothrombin time, and mild to modest increase of serum aminotransferase levels. She died in 6 weeks. Postmortem liver histology showed canalicular and cellular cholestasis and ground-glass appearance and ballooning of most hepatocytes, but only mild inflammatory cell infiltration. Immunohistochemical staining showed massive loads of hepatitis B surface and core antigens in the hepatocytes and extensive periportal fibrosis. The whole picture was compatible with fibrosing cholestatic hepatitis described in hepatitis B virus-infected liver transplant. Sequencing of the hepatitis B virus genome amplified from the patient's serum indicated a precore mutant but few mutations in the core, pre-S, and S genes. Little inflammatory reaction was observed histologically despite HLA compatibility, a situation differing from that in liver transplant. This observation indicates that fibrosing cholestatic hepatitis may also occur in non-liver transplant setting.