The introduction of hepatitis B vaccination and infection control in 1977 has greatly decreased the prevalence of hepatitis B. Currently, approximately 2.8% of the end-stage renal disease population is hepatitis B positive with a presence in 27.7% of the USA hemodialysis (HD) units according to the Dialysis Outcomes and Practice Patterns Study data. The behavior of hepatitis B infection differs significantly between immunocompetent and immunosuppressed hosts. Immunosuppressed hosts present more subtly with complications of chronic hepatitis B infection, being more challenging to detect. It is also well known that patients with chronic infection on HD have a small chance of clearing the virus. We report here a case of a hepatitis B positive HD patient who underwent spontaneous delayed serological clearance of hepatitis B surface antigen and development of immunity via appearance of hepatitis B surface antibody. This is a rare occurrence, and the few similar reported cases will be discussed.