As medical director of an outpatient hemodialysis facility you have received a referral to admit a new patient to your unit In reviewing his records it seems that he has not been vaccinated against HBV Before admission which of the following tests should be completed ID: 934445
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Slide1
Hepatitis B in dialysis
Anna Vinnikova, MD
Slide2As medical director of an outpatient hemodialysis facility, you have received a referral to admit a new patient to your unit. In reviewing his records, it seems that he has not been vaccinated against HBV. Before admission, which of the following tests should be completed?
A. Hepatitis B surface antigen (HBsAg) and antibody to hepatitis B core antigen (anti-HBc)B. HBsAg and antibody to HBsAg (anti-HBs)C. HBsAg, anti-HBs, and anti-HBc
D. HBsAg, anti-HBs, and hepatitis B e-antigen
Slide3Q1As medical director of an outpatient hemodialysis facility, you have received a referral to admit a new patient to your unit. In reviewing his records, it seems that he has not been vaccinated against HBV. Before admission, which of the following tests should be completed?
A. Hepatitis B surface antigen (HBsAg) and antibody to hepatitis B core antigen (anti-HBc)B. HBsAg and antibody to HBsAg (anti-HBs)C.
HBsAg, anti-HBs, and anti-HBcD. HBsAg, anti-HBs, and hepatitis B e-antigen
Slide4HBV
+ HBsAg = infection (or transient + post vaccination)+ HBcAb = exposure
+ HBsAb = immunity+ HBeAg = high infectivity
Slide5HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
Negative
New admission 1
Labs from the referring facility:
Slide6HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
Negative
No exposure, susceptible
Repeat serologies in your facility within 30 d of admission
Plan full vaccination series
New admission 1
Labs from the referring facility:
Slide7HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
Negative
No exposure, susceptible
Repeat serologies in your facility within 30 d of admission
Plan full vaccination series
New admission 1
Labs from the referring facility:
Labs at your facility:
HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
Negative
Slide8HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
Negative
No exposure, susceptible
Repeat serologies in your facility within 30 d of admission
Plan full vaccination series
New admission 1
Labs from the referring facility:
Labs at your facility:
HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
Negative
No exposure, susceptible
Plan full vaccination series
Slide9HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
(Not so)new admission 1
Patient received vaccination series with high dose Hep B vaccine (40 mcg), and serologies repeated 1
mo
after completion:
Slide10HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
No response
Repeat full vaccination series with 40 mcg
(Not so)new admission 1
Patient received vaccination series with high dose Hep B vaccine (40 mcg), and serologies repeated 1
mo
after completion:
Slide11HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
No response
Repeat full vaccination series with 40 mcg
(Not so)new admission 1
Patient received vaccination series with high dose Hep B vaccine (40 mcg), and serologies repeated 1
mo
after completion:
Patient received second vaccination series with high dose Hep B vaccine (40 mcg),
and serologies repeated 1
mo
after completion:
HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
Slide12HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
No response
Repeat full vaccination series with 40 mcg
(Not so)new admission 1
Patient received vaccination series with high dose Hep B vaccine (40 mcg), and serologies repeated 1
mo
after completion:
Patient received second vaccination series with high dose Hep B vaccine (40 mcg),
and serologies repeated 1
mo
after completion:
HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
No response
No further vaccination
Check HBsAg monthly
Slide13HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
No response
Repeat full vaccination series with 40 mcg
(Not so)new admission 1 alternate reality
Patient received vaccination series with high dose Hep B vaccine (40 mcg), and serologies repeated 1
mo
after completion:
Patient received second vaccination series with high dose Hep B vaccine (40 mcg),
and serologies repeated 1
mo
after completion:
HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Positive
Slide14HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
No response
Repeat full vaccination series with 40 mcg
(Not so)new admission 1 alternative reality
Patient received vaccination series with high dose Hep B vaccine (40 mcg), and serologies repeated 1
mo
after completion:
Patient received second vaccination series with high dose Hep B vaccine (40 mcg),
and serologies repeated 1
mo
after completion:
HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Positive
Responded, immune
Repeat anti-HBs annually
Slide15HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
Negative
No exposure, susceptible
Repeat serologies in your facility within 30 d of admission
Plan full vaccination series
New admission 2
Labs from the referring facility:
Labs at your facility:
HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Positive
Negative
Negative
Slide16HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
Negative
No exposure, susceptible
Repeat serologies in your facility within 30 d of admission
Plan full vaccination series
New admission 2
Labs from the referring facility:
Labs at your facility:
HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Positive
Negative
Negative
!!!Seroconversion!!!
This will be reported to state and is likely to trigger a state survey
Likely unreported vaccination prior to admission, but can’t r/o early infection
Treat patient as infections. If there’s no isolation room in the facility, create a buffer zone of 2 immune patients on each side of this patient
Medical eval, can send LFTs, Anti-HBc IgM,
HBeAg
and HBV DNA
Investigate vaccination history
Repeat labs 4
wks
after that vaccination date
Slide17HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Positive
Negative
New admission 3
Slide18HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Positive
Negative
Vaccinated/immune
Recheck Anti-HBs annually
New admission 3
Slide19HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Positive
Positive
New admission 4
Slide20HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Positive
Positive
Prior infection, recovered
Natural immunity
No retesting
New admission 4
Slide21HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Positive
Negative
Positive
New admission 5
Labs from the referring facility:
Slide22HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Positive
Negative
Positive
Acute or chronic infection,
contagious
Request Anti-HBc IgM
Do not accept admission yet
New admission 5
Labs from the referring facility:
Slide23HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Positive
Negative
Positive
Acute or chronic infection,
contagious
Request Anti-HBc IgM
Do not accept admission yet
New admission 5
Labs from the referring facility:
HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Positive
Negative
Positive
Positive
Requested labs from the referring facility:
Slide24HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Positive
Negative
Positive
Acute or chronic infection,
contagious
Request Anti-HBc IgM
Do not accept admission yet
New admission 5
Labs from the referring facility:
HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Positive
Negative
Positive
Positive
Acute infection, contagious, may be sick
Accept patient only if facility has HBV isolation room
Make sure the patient is stable for outpatient HD
Request results of medical evaluation and treatment plan
Requested labs from the referring facility:
Slide25HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Positive
Negative
Positive
Acute or chronic infection,
contagious
Request Anti-HBc IgM
Do not accept admission yet
New admission 6
Labs from the referring facility:
HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Positive
Negative
Negative
Positive
Requested labs from the referring facility:
Slide26HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Positive
Negative
Positive
Acute or chronic infection,
contagious
Request Anti-HBc IgM
Do not accept admission yet
New admission 6
Labs from the referring facility:
HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Positive
Negative
Negative
Positive
Chronic infection, contagious
Accept patient only if facility has HBV isolation room
Request results of medical evaluation and treatment plan
Requested labs from the referring facility:
Slide27HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
Positive
New admission 7
Labs from the referring facility:
Slide28HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
Positive
Several possibilities:
1. Resolved infection with undetectable anti-HBs
(may be immune or susceptible)
2. False-positive anti-HBc (susceptible)
3. Low-level chronic infection 4. Resolving acute infection (Anti-HBc IgM +)Repeat to r/o error
Check Anti-HBc IgM to r/o acute infectionAdditional tests to confirm chronic infection (HBeAg
, HBV DNA)
If all other tests unrevealing, vaccinate with one full series
New admission 7
Labs from the referring facility:
Slide29HBsAg
Anti-HBs
Anti-HBc
Interpretation
Orders
IgM
Total
Negative
Negative
Negative
Negative
No exposure
Susceptible to infection, prescribe vaccination series
Negative
Positive
Negative
Negative
Successful vaccination, acquired immunity
Check anti-HBs Ab yearly
Negative
Positive
Negative
Positive
Cleared infection, natural immunity
No further testing
Positive
Negative
Negative
Negative
Early infection (first 2-4
wk
) or false positive
Isolate as infective, repeat HBsAg
Positive
Negative
Positive
Positive
Acute infection
Isolate as infective
Positive
Negative
Negative
Positive
Chronic infection
Isolate as infective, vaccinate?
Negative
Negative
Negative or
positive
Positive
4 possibilities:
1.Resolved infection with undetectable anti-HBs
2.False-positive anti-HBc, susceptible
3.Low-level chronic infection, not infectious
4.Resolving acute infection
Patient needs further testing, booster
HBV summary table
Slide30ReferencesA very good AJKD Core Curriculum article (for the boards)https://www.ajkd.org/article/S0272-6386(20)30611-9/fulltextAn extremely current CDC publication (yep, this is the latest!) – good for looking up special situations when you are a medical director
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm