Can a kidney transplant be performed in a patient with Hepatitis B (HBV) infection?

Kidney Transplantation in Hepatitis B Positive Recipients

Yes, kidney transplantation can and should be performed in Hepatitis B positive (HBsAg+) recipients, as it offers superior survival compared to remaining on dialysis, provided appropriate antiviral prophylaxis is initiated and maintained long-term. 1

Pre-Transplant Requirements

Mandatory Screening and Assessment

• All kidney transplant candidates must be screened for HBV markers including HBsAg, anti-HBs, anti-HBc, and HBV DNA levels 1
• Liver function assessment is essential through ALT/AST monitoring and consideration of liver biopsy to exclude cirrhosis, as decompensated cirrhosis would require combined kidney-liver transplantation rather than kidney alone 2, 3
• HBV DNA quantification must be performed to determine viral replication status and guide treatment intensity 2

Pre-Transplant Antiviral Therapy

• Treatment-naïve HBsAg+ patients should receive entecavir (ETV) or tenofovir alafenamide (TAF) prior to transplantation if detectable HBV DNA is present 1
• Lamivudine is not recommended due to high resistance rates, though it was used historically 1, 3
• Tenofovir disoproxil fumarate (TDF) should be avoided in kidney transplant candidates due to nephrotoxicity concerns; reserve only for nucleoside-resistant cases if TAF unavailable 1, 3

Post-Transplant Management

Universal Antiviral Prophylaxis

• All HBsAg-positive kidney transplant recipients must receive long-term antiviral prophylaxis or treatment with nucleos(t)ide analogues (NAs) starting perioperatively 1, 2
• ETV or TAF are the preferred first-line agents for both treatment-naïve and post-transplant recipients 1
• Prophylaxis should be continued indefinitely during maintenance immunosuppression, as long-term NA therapy reduces liver complications and improves survival 1, 2

Critical Monitoring Requirements

• Renal function must be carefully monitored during NA therapy, with dose adjustments or treatment changes if unexpected deterioration occurs 1
• HBV DNA and liver enzymes should be monitored regularly to detect viral breakthrough or hepatotoxicity 2, 3
• Optimal control of hypertension and diabetes is essential in these recipients 1

Immunosuppression Considerations

• All standard immunosuppressive agents can be used in HBV-positive recipients, though total immunosuppression burden should be minimized long-term as it increases viral replication 2
• Pegylated interferon-alpha is absolutely contraindicated due to risk of allograft rejection 1

Transplant Outcomes

Survival Data

• Patient and graft survival rates in HBsAg+ recipients approach those of HBsAg-negative recipients when appropriate antiviral therapy is used 1, 2, 4
• Kidney transplantation provides superior mortality benefit compared to remaining on dialysis for HBV-infected patients 1, 2
• Medium-term data demonstrate comparable outcomes between HBsAg+ and HBsAg- recipients in the era of effective antiviral therapies 3

Special Considerations for Donor Selection

HBsAg-Positive Donors

• Kidneys from HBsAg+ donors can be successfully transplanted into HBsAg+ recipients with appropriate antiviral coverage 1, 4
• HBV-immune recipients (anti-HBs+ with titers >100 IU/L) can receive HBsAg+ kidneys with HBIG and/or antiviral prophylaxis, though some studies show success without prophylaxis in highly immune recipients 1
• One fatal case of fulminant HBV has been reported in an immunized recipient who received HBIG but not antiviral prophylaxis, underscoring the importance of comprehensive prophylaxis 1

Anti-HBc Positive Donors

• Kidneys from anti-HBc+/HBsAg- donors carry low transmission risk and should not be considered marginal organs 4
• Booster vaccination or prophylactic antivirals can prevent post-transplant HBV infection from these donors 4

Common Pitfalls to Avoid

• Never withhold transplantation solely based on HBV status – this denies patients the survival benefit of transplantation 1, 2
• Never use lamivudine as first-line therapy due to high resistance rates (up to 70% at 5 years) 1, 3
• Never discontinue antiviral prophylaxis arbitrarily – maintain throughout immunosuppression unless carefully selected low-risk scenario with close monitoring 2
• Never use TDF as first-line in kidney transplant recipients given renal toxicity concerns; ETV or TAF are safer choices 1
• Never forget to assess for cirrhosis pre-transplant – decompensated cirrhosis requires combined kidney-liver transplantation 2, 3