Hepatitis B, C, and E viruses in solid organ transplantation: donor and recipient perspectives

Solid organ transplantation (SOT) presents a unique intersection of life-saving opportunity and infectious risk. This review examines the implications of hepatitis B, C, and E from both donor and recipient perspectives and provides updated evidence-based management strategies. Advances in antiviral therapies have enabled the safe utilization of HBV- and HCV- infected donors, which can expand the donor pool without compromising recipient outcomes. For HBV, nucleos(t)ide analogs provide effective prophylaxis and treatment, and emerging data support using HBsAg+ donors in HBV-naive recipients with proper management. In the case of HCV, direct-acting antivirals (DAAs) have revolutionized transplant medicine, allowing the routine use of HCV-viremic donors. Both preemptive and prophylactic treatment strategies are discussed, with growing support for short-course DAA regimens in cardiothoracic transplant. HEV, though less commonly screened, poses a risk for chronic infection in immunocompromised hosts and can lead to graft dysfunction or rejection. Ribavirin remains the mainstay of treatment, and the potential for donor-derived HEV transmission highlights the importance of surveillance and, where available, screening protocols. This review proposes practical algorithms for pre- and post-transplant management and outlines future directions in vaccine development, viral screening, and antiviral therapies. A tailored, virus-specific approach informed by both donor and recipient virologic status is essential to optimize patient and graft outcomes while ensuring safe expansion of the donor organ pool.