Kidney transplant from donors with hepatitis B: A challenging treatment option

Utilization of Hepatitis B viremic donors (NAT+) leads to improved kidney transplant access for older adult recipients with little to no wait time

BACKGROUND

Though the use of Hepatitis B viremic (HBV) donor kidneys may be a safe alternative to improve access to transplantation, there has not been wide acceptance of this practice. In this study, we determined the safety and effectiveness of HBV NAT (+) donor kidneys in a protocolized manner in an older adult population.

METHODS

Over a 3-year period, 16 decreased donor kidney transplants were performed with HBV NAT+ kidneys. Recipients of HBV NAT+ kidneys were treated with entecavir started pre-operatively and continued for 52 weeks.

RESULTS

HBV NAT+ kidneys were preferentially used in older (68 ± 5 vs. 64 ± 9 years; p = .01) recipients with less dialysis time (93.8% < 5 years vs. 67% <5 years; p = .03). In this cohort, 3/16 had detectable HBV PCR 1-week post-transplant, but all were negative at 9- and 12-months. Calculated estimated glomerular filtration rate (eGFR) was slightly decreased 12-months post-transplant. Post-transplant outcomes in an age-matched cohort showed no difference in rates of delayed graft function, readmission within 30 days, and graft loss or death within 6 months of transplant (p > .05).

CONCLUSION

Transplants with HBV NAT+ donor kidneys in a pre-emptive treatment protocol allow for increased safe access to transplantation in older adult recipients with little or no dialysis time.

An Anatomically Complicated Living Donor Kidney Transplantation from Hepatitis B Surface Antigen-Positive Donor to Negative Recipient With Size Discrepancy

The deficiency of organ donors remains a barrier to kidney transplantation. Living donor kidney transplantation (LDKT) can overcome graft shortage, resulting in better outcomes. Many efforts are being made to expand the donor pool, such as hepatitis B surface antigen (HBsAg)-positive donors to negative recipients and anatomically complicated donor kidneys with size discrepancies. We report a case in which we overcame various problems in LDKT. The recipient was a 56-year-old, 106-kg, HBsAg negative male with diabetic nephropathy. The donor was a 63-year-old female, 56-kg, hepatitis B virus (HBV) carrier with dual renal arteries. Preoperative antiviral medication was provided to the donor for negative conversion of HBV-DNA. The recipient was given HBV vaccination (antihepatitis B antibody: 2.25-36.16 mIU/mL). Anti-HBV immunoglobulin was intraoperatively administered to prevent transmission. The donor and recipient had an absolute weight difference (50 kg). In addition, the donor's kidney had a main and an accessory artery in the upper pole, which were anastomosed to the recipient's right external iliac and inferior epigastric artery, respectively. Follow-up serum creatinine levels decreased. Doppler ultrasonography showed good vascular flow within the reference range of the resistive index. The recipient's follow-up HBV-DNA titer was negative with antiviral medication. We successfully performed LDKT from an HBV-positive donor to a negative recipient by perioperative antiviral treatment and overcame a significant size discrepancy and anatomic challenges by preserving even a small portion of the kidney graft.

Clinical Significance and Remaining Issues of Anti-HBc Antibody and HBV Core-Related Antigen

Currently, hepatitis B virus (HBV) core antibody (anti-HBc antibody) and HBV core-related antigen (HBcrAg) are widely used as serum markers for diagnosis based on the HBV core region. This review focused on anti-HBc antibodies and HBcrAg and aimed to summarize the clinical significance of currently used assay systems and the issues involved. While anti-HBc is very significant for clinical diagnosis, the clinical significance of quantitative assay of anti-HBc antibody has been reevaluated with improvements in diagnostic performance, including its association with clinical stage and prediction of carcinogenesis and reactivation. In addition, concerning the new HBcrAg, a high-sensitivity assay method has recently been established, and its diagnostic significance, including the prediction of reactivation, is being reevaluated. On the other hand, the quantitative level of anti-HBc antibody expressed in different units among assay systems complicates the interpretation of the results. However, it is difficult to standardize assay systems as they vary in advantages, and caution is needed in interpreting the assay results. In conclusion, with the development of highly sensitive HBcrAg and anti-HBc antibody, a rapid and sensitive detection assay system has been developed and used in clinical practice. In the future, it is hoped that a global standard will be created based on the many clinical findings.