The Outcomes of Kidney Transplantation in Hepatitis B Surface Antigen (HBsAg)–Negative Recipients Receiving Graft From HBsAg-Positive Donors: A Retrospective, Propensity Score-Matched Study

Abstract

The outcomes of kidney transplantation (KT) from hepatitis B surface antigen-positive [HBsAg(þ)] donors to HBsAg(À) recipients remain inconclusive, possibly due to substantial differences in methodological and statistical models, number of patients, follow-up duration, hepatitis B virus (HBV) prophylactic regimens and hepatitis B surface antibody (anti-HBs) levels. The present retrospective, longitudinal study (clinicaltrial. gov NCT02044588) using propensity score matching technique was conducted to compare outcomes of KT between HBsAg(À) recipients with anti-HBs titer above 100 mIU/mL undergoing KT from HBsAg(þ) donors (n ¼ 43) and HBsAg(À) donors (n ¼ 86). During the median follow-up duration of 58.2 months (range 16.7-158.3 months), there were no significant differences in graft and patient survivals. No HBV-infective markers, including HBsAg, hepatitis B core antibody, hepatitis B extracellular antigen and HBV DNA quantitative test were detected in HBsAg(þ) donor group. Renal pathology outcomes revealed comparable incidences of kidney allograft rejection while there were no incidences of HBV-associated glomerulonephritis and viral antigen staining. Recipients undergoing KT from HBsAg(þ) donors with no HBV prophylaxis (n ¼ 20) provided comparable outcomes with those treated with lamivudine alone (n ¼ 21) or lamivudine in combination with HBV immunoglobulin (n ¼ 2). In conclusion, KT without HBV prophylaxis from HBsAg(þ) donors without hepatitis B viremia to HBsAg(À) recipients with anti-HBs titer above 100 mIU/mL provides excellent graft and patient survivals without evidence of HBV transmission.

Kidney Transplantation From Donors with Hepatitis B

“…A documented serum anti-HBs level more than 10 IU/mL after vaccination of a naïve patient is considered to confer protective immunity against primary HBV infection and exposure. This anti-HBs level confers immunity even in recipients of HBcAb-positive organs [ 28 – 30 ]. Therefore, kidneys from HBcAb-positive donors are preferably allocated to successfully immunized patients or HbsAg-positive recipients [ 2 , 11 , 22 – 24 ].…”

“…However, implementing anti-HBV prophylaxis in all recipients does not seem reasonable [ 15 ] since the risk of transmission of infection through transplantation seems to be very low [ 33 ]. Moreover, patients who develop inactive carrier status, as well as patients who become chronic carriers with active HBV replication, should be treated like immunocompetent patients with nucleo(s)tide analogues with high efficacy and low resistance [ 15 – 30 , 33 , 34 ].…”

“…In the liver transplant setting, prophylaxis with lamivudine and/or HBIg reduces rates of de novo HBV infection from 58% to 11% in HBV non-immune recipients; 18% to 2% in previously vaccinated recipients; and 14% to 3% in isolated HBcAb positive recipients [ 28 ], and this benefit is higher when lamivudine is used as monotherapy [ 28 – 30 , 35 , 36 ]. Recently, the introduction of effective nucleo(s)tide analogs (NA) entecavir and tenofovir has improved the outcome of patients with chronic hepatitis B and the combination of NA and HBIg is now considered the standard of care for prophylaxis against HBV recurrence after liver transplantation [ 37 ], while entecavir has replaced lamivudine as first-line therapy for treatment-naïve recipients in view of the propensity for drug resistance [ 38 ].…”

Solid Organ Transplantation From Hepatitis B Virus–Positive Donors: Consensus Guidelines for Recipient Management

“…In another study, four naturally immune recipients were also treated with 1 year of lamivudine with no evidence of HBV transmission . In a recent study, the patient and graft survival after a median of 58.2 months was not different in HBsAg– recipients with anti‐HBs titers >100 IU/L regardless of whether their graft was acquired from a HBsAg+ or HBsAg– donor . None of the 43 recipients of an HBsAg+ graft acquired HBV including 20 patients who received no prophylaxis.…”

Untitled

“…57 In a recent study, the patient and graft survival after a median of 58.2 months was not different in HBsAg negative recipients with anti-HBs titers > 100 IU/L regardless of whether their graft was acquired from a HBsAg-positive or HBsAgnegative donor. 58 Of note are reports of fatal fulminant HBV after kidney transplant in a previously immunized (anti-HBs-positive) recipient from an HBsAg-positive donor. Although HBIG and a supplemental dose of HBV vaccine were administered, antiviral prophylaxis was not given in this case.…”