From the Guidelines
When a hepatitis B surface antigen (HBsAg) positive donor's lungs are transplanted into a hepatitis B vaccinated recipient, prophylactic antiviral therapy with entecavir 0.5 mg daily or tenofovir 300 mg daily should be initiated immediately post-transplant and continued indefinitely to prevent viral reactivation, as recommended by the most recent guidelines 1. The recipient's prior vaccination does not guarantee complete protection against hepatitis B infection due to immunosuppression post-transplant, which can impair vaccine-induced immunity.
- The combination of antiviral therapy provides direct inhibition of viral replication.
- Regular monitoring of hepatitis B viral load, liver function tests, and HBsAg status should be performed every 1-3 months initially, then every 3-6 months long-term.
- Patients should be counseled about medication adherence, as interruption of antiviral therapy could lead to viral breakthrough and potentially fulminant hepatitis. Key considerations in the management of such patients include:
- The risk of donor-derived hepatitis B transmission, which can be significantly reduced with the use of antiviral therapy 1.
- The importance of monitoring for hepatitis B infection, even in vaccinated recipients, due to the potential for immunosuppression to impair vaccine-induced immunity.
- The need for lifelong antiviral therapy to prevent viral reactivation, as recommended by the most recent guidelines 1.
From the Research
Key Considerations
- The use of hepatitis B core antibody positive (HBcAb+) donors for lung transplantation in hepatitis B vaccinated patients is considered safe and effective, as shown in a study published in 2005 2.
- A study from 2025 found that transplanting lungs from hepatitis B virus (HBV) nucleic acid positive (NAT+) donors to HBV vaccinated candidates can be safe, but strict eligibility criteria and donor selection are crucial 3.
- Antiviral prophylaxis, such as hepatitis B immunoglobulin (HBIG) and nucleos(t)ide analogues (NAs), is essential to prevent HBV recurrence after transplantation 4.
- The use of HBV-positive organs in organ transplantation is feasible, and outcomes have been excellent with appropriate prophylactic therapies 5.
Plan of Management
- Recipients of HBV NAT+ organs should receive intravenous HBIG and appropriate HBV antiviral therapy 3.
- Lifelong antiviral prophylaxis may be necessary for patients receiving grafts from HBcAb+ donors 4.
- NAs, such as entecavir or tenofovir, can be used as monoprophylaxis after a short period of HBIG and NA combination 4.
- Close monitoring of liver function, viral hepatitis screening tests, and quantitative polymerase chain reaction for HBV DNA is essential to prevent HBV recurrence 2.
Donor Selection
- Donors with HBcAb+ status can be considered safe for transplantation in HBV vaccinated recipients 2.
- Donors with HBV NAT+ status require careful selection and strict eligibility criteria 3.
- Concurrent hepatitis C virus (HCV) infection in donors is a contraindication for transplantation in HBV vaccinated recipients 2.