Can a kidney donor who is anti‑HBc total positive donate a kidney?

Can Anti-HBc Total Positive Donors Donate Kidneys?

Yes, anti-HBc total positive donors can safely donate kidneys, and this practice is explicitly supported by consensus guidelines to expand the donor pool. 1

Evidence Supporting Anti-HBc Positive Kidney Donation

The American Society of Transplantation consensus guidelines explicitly state that HBV-positive donors (including anti-HBc positive donors) should be considered for donation to safely expand the organ pool. 2 The key data supporting this practice includes:

• In a review of 1,385 HBsAg-negative kidney recipients from anti-HBc+ donors, the rate of HBsAg acquisition was only 0.28% (4/1385) with no evidence of symptomatic hepatitis. 1

• Patient and graft outcomes were not worse among patients with HBsAg acquisition or evidence of anti-HBs or anti-HBc seroconversion. 1

• The largest UNOS database study showed HBsAg acquisition occurred at similar rates from anti-HBc+ donors (0.001 cases per year) compared to anti-HBc-negative donors (0.003 cases per year). 1

Risk Stratification Based on Recipient Status

The transmission risk and management strategy depends critically on the recipient's HBV immunity status:

Recipients with HBV Immunity (Anti-HBs+ or Prior HBV)

• Clinical hepatitis has not been noted in immunized individuals following kidney transplantation from anti-HBc+ donors, possibly due to partial protection from vaccination. 1
• No prophylaxis is typically required for immune recipients. 1
• These recipients can safely receive anti-HBc+ kidneys without significant transmission risk. 3

HBV-Naive Recipients (No Prior Exposure or Vaccination)

• HBV vaccination prior to transplant with target anti-HBs titers >10 IU/L has been demonstrated to be protective for renal recipients of anti-HBc+ donors. 1
• Higher antibody titers provide better protection: risk of anti-HBc seroconversion was 4% when anti-HBs titers were >100 IU/L compared to 10% when <100 IU/L. 1
• In one observational study of 46 kidney recipients from anti-HBc+ organs, there was no evidence of HBV transmission after a median of 36 months when non-immune recipients were treated with lamivudine for 1 year. 1

HBsAg-Positive Recipients

• Kidneys from anti-HBc+ donors can be successfully transplanted into HBsAg+ recipients with appropriate antiviral coverage. 4
• These recipients already require long-term antiviral therapy regardless of donor status. 4

Recommended Management Algorithm

Step 1: Confirm Donor Serologic Status

• Verify donor is HBsAg-negative and anti-HBc total positive. 1, 2
• Additional testing for anti-HBs status in the donor does not impact transmission risk but may be performed. 1

Step 2: Assess Recipient HBV Status

• Check recipient HBsAg, anti-HBs, anti-HBc, and HBV DNA levels. 4
• Measure quantitative anti-HBs titers if recipient has been vaccinated. 1

Step 3: Implement Risk-Stratified Prophylaxis

• If recipient is HBV-immune (anti-HBs >10 IU/L): No prophylaxis required; proceed with transplantation. 1
• If recipient is HBV-naive: Either vaccinate pre-transplant to achieve anti-HBs >10 IU/L (preferably >100 IU/L) OR provide antiviral prophylaxis (lamivudine for 1 year or entecavir/tenofovir). 1
• If recipient is HBsAg-positive: Continue or initiate long-term antiviral therapy with entecavir or tenofovir. 4

Step 4: Post-Transplant Monitoring

• Monitor for HBsAg and HBV DNA at regular intervals (6,12,24, and 36 months). 1
• Check for anti-HBc or anti-HBs seroconversion. 1

Critical Distinctions from Liver Transplantation

The risk profile for kidney transplantation from anti-HBc+ donors is fundamentally different from liver transplantation:

• Transmission risk is significantly lower in kidney recipients compared to liver recipients. 1, 5
• No HBV transmission was observed in kidney recipients from anti-HBc+ donors independent of recipient immunological profile in multiple studies. 5
• In contrast, liver recipients show a 43% de novo hepatitis rate in naive patients without prophylaxis. 5

Common Pitfalls to Avoid

Do not reject anti-HBc+ kidney donors automatically. This unnecessarily discards viable organs when safe use protocols exist. 1, 2, 3

Do not use HBIG routinely in kidney recipients. There is likely no role for HBIG in the setting of antiviral prophylaxis, and data demonstrating benefit in kidney recipients are lacking. 1

Do not use lamivudine as first-line if choosing antiviral prophylaxis. While lamivudine has been studied extensively, entecavir and tenofovir have superior resistance profiles. 1, 4

Do not assume isolated anti-HBc positivity always represents true HBV exposure. False-positive results can occur and should be considered, though this does not change the safety of proceeding with donation. 6

Do not confuse anti-HBc+ donors with HBsAg+ donors. HBsAg-positive donors carry much higher transmission risk and are generally contraindicated except for HBsAg-positive recipients or those with protective immunity. 2, 3