Management issues for transplant recipients
Hepatitis B. Transplantation from an HBsAg-positive donor. Traditionally, these donors have not been used for liver transplants because the risk of HBV transmission is high. In the current era, with the shortage of transplantable organs, the possibility of pretransplant vaccination of the recipient, and the availability of more effective drugs for hepatitis B treatment, this position may need to be reassessed.

With respect to nonhepatic (kidney, heart, lung) organ donation, there are conflicting reports regarding the risk of HBV transmission. In 1 survey of renal transplant recipients, the cumulative risk of developing posttransplant hepatitis was significantly higher in HBsAg-positive patients (P = .001).⁴⁴⁹

In bone marrow transplantation, abnormal ALT levels in donors are a significant predictor of potentially lethal liver complications in HBsAg-positive individuals.⁴⁵⁰ Hepatitis B virus carriers receiving a marrow graft from an HBsAg-positive donor have been shown to be at increased risk.⁴⁵¹ In another report, the use of HBsAg-positive donors, particularly if they were also positive for anti-HBe, increased the risk of severe liver disease in bone marrow transplant recipients.^450,452 At the moment, organs from HBsAg carriers cannot be used.

Transplantation from an HBsAg-negative, anti-HBc–positive donor. HBsAg-negative and anti-HBc– positive donors generally have not been used in liver transplants, as de novo posttransplantation HBV infection occurs in recipients of donors with anti-HBc. Transmission of HBV through transplantation suggests that the virus may persist in the liver despite serologic resolution of infection.²¹ In 1 study of 332 transplants performed before exclusion of anti-HBc–positive liver donors, 3% of donors were anti-HBc–positive; 33% of recipients developed transplant-associated de novo HBV infections compared with only 0.5% of recipients who received anti-HBc–negative donor livers (P = .00014). Of the 9 recipients of anti-HBc–positive livers, 67% were alive at the time of publication, and no deaths or allograft failures have been related to complications of hepatitis B. One of 5 patients with de novo hepatitis B and high levels of viremia developed graft dysfunction after follow-up of more than 7 years (range, 63 to 124 months).⁴⁵³ Of note, in the current era of organ shortage, the usefulness of these "suboptimal organs" is being reassessed.

However, for nonhepatic transplants the risk is thought to be relatively low, especially in the vaccinated recipient, and these organs may be considered. Data on the efficacy of prophylaxis with anti-HBV agents such as lamivudine and famciclovir are not established.