Kidney Transplantation in Hepatitis B Positive Recipients

Pre-Transplant Requirements

The American Association for the Study of Liver Diseases and the European Association for the Study of the Liver recommend that all kidney transplant candidates must be screened for HBV markers, including HBsAg, anti-HBs, anti-HBc, and HBV DNA levels 1, 2
Treatment-naïve HBsAg+ patients should receive entecavir (ETV) or tenofovir alafenamide (TAF) prior to transplantation if detectable HBV DNA is present, as recommended by the American Association for the Study of Liver Diseases 1, 2, 3

The American Society of Transplantation recommends that all HBsAg-positive kidney transplant recipients must receive long-term antiviral prophylaxis or treatment with nucleos(t)ide analogues (NAs) starting perioperatively 1, 2, 3
ETV or TAF are the preferred first-line agents for both treatment-naïve and post-transplant recipients, according to the European Association for the Study of the Liver 1, 2, 3
Prophylaxis should be continued indefinitely during maintenance immunosuppression, as long-term NA therapy reduces liver complications and improves survival, as recommended by the American Association for the Study of Liver Diseases 1, 2

Patient and graft survival rates in HBsAg+ recipients approach those of HBsAg-negative recipients when appropriate antiviral therapy is used, according to the American Society of Transplantation 4
Kidney transplantation provides superior mortality benefit compared to remaining on dialysis for HBV-infected patients, as recommended by the American Association for the Study of Liver Diseases 1

Kidneys from HBsAg+ donors can be successfully transplanted into HBsAg+ recipients with appropriate antiviral coverage, according to the American Society of Transplantation 4, 5, 6
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, as reported by the American Journal of Transplantation 4, 5, 6

The American Association for the Study of Liver Diseases recommends that transplantation should not be withheld solely based on HBV status, as this denies patients the survival benefit of transplantation 1
Lamivudine should not be used as first-line therapy due to high resistance rates, according to the European Association for the Study of the Liver 1, 2
TDF should not be used as first-line in kidney transplant recipients given renal toxicity concerns; ETV or TAF are safer choices, as recommended by the American Association for the Study of Liver Diseases 1, 2