Using Hepatitis B Surface Antigen-Positive Donors in Liver Transplantation: Outcomes, Prophylaxis, and Monitoring...

Liver transplantation (LT) remains the only definitive treatment for end-stage liver disease and selected hepatic malignancies. However, persistent organ shortages continue to drive high waitlist mortality worldwide. Hepatitis B virus (HBV)-positive donors, including hepatitis B surface antigen (HBsAg)-positive and anti-hepatitis B core antibody-positive (HBsAg-negative) donors, represent an increasingly important but historically underused resource. The introduction of high-barrier nucleos(t)ide analogs, the selective use of hepatitis B immunoglobulin, and pre- and posttransplant vaccination have markedly reduced viral transmission, enabling safe transplantation in both HBV-immune and selected HBV-naive recipients. Regional guidelines and consensus statements, including those from the American Society of Transplantation, European Association for the Study of the Liver, American Association for the Study of Liver Diseases, and Asian Pacific Association for the Study of the Liver, support individualized, risk-directed prophylaxis and posttransplant surveillance. Ethical considerations, particularly informed consent and risk-benefit discussions in the setting of organ scarcity, remain central to clinical decision-making. Large cohort studies demonstrate comparable graft and patient survival with HBV-negative grafts, along with economic advantages and expansion of the donor pool. However, evidence in HBV-naive recipients remains limited, with most data derived from immune or previously infected recipients, highlighting the need for careful patient selection and robust prophylaxis. Available evidence on the use of HBsAg-positive donors in HBV-naive recipients is obtained predominantly from cadaveric donor transplantation, as experience with HBsAg-positive living donors remains limited. This narrative review summarizes current evidence on the use of HBsAg-positive grafts in LT, with a focus on HBV-naive recipients, based predominantly on cadaveric donor experience.