Mortality and Kidney Failure Risk in HBsAg-Positive Living Kidney Donors: A Retrospective Cohort Study

Living donors with hepatitis B virus (HBV) infection are increasingly accepted to alleviate organ shortages. However, after donor nephrectomy, the impact of HBV infection on long-term kidney function remains unclear in individuals with a solitary functioning kidney.

We conducted a retrospective controlled cohort study to evaluate long-term kidney and liver function, risk of end-stage kidney disease (ESKD), cancer-specific mortality, and all-cause mortality between hepatitis B surface antigen-positive (HBsAg+) donors and HBsAg- donors. Multivariable Cox proportional hazards regression was used to estimate hazard ratios (HR).

We included 128 HBsAg+ donors and 1145 HBsAg- donors. After a median follow-up of 86.0 and 96.0 months, HBsAg+ donors demonstrated a greater increase in serum creatinine compared to HBsAg- donors (12.1 µmol/L vs. 8.4 µmol/L, p < 0.001). The rates of ESKD were 0.58 and 2.94 per 1000 person-years, and the rates of estimated glomerular filtration rate (eGFR) < 45 mL/min/1.73 m² were 3.65 and 9.99 per 1000 person-years in the HBsAg- and HBsAg+ donors. Further, HBsAg+ donors had a higher risk of eGFR < 45 mL/min/1.73 m² (HR: 2.21, 95% confidence interval [CI]: 1.06-4.63, p = 0.035). The mortality was 1.4 and 6.85 per 1000 person-years in HBsAg- and HBsAg+ donors, respectively. After full adjustment, HBsAg+ status was an independent risk factor of death (HR: 7.16, 95% CI: 1.71-29.92, p = 0.007). Sensitivity analyses after propensity score matching reported numerically higher incidence of ESKD and marginally higher incidence of eGFR < 45 mL/min/1.73 m². Stratified analyses revealed that hepatitis B e antigen-positive status (p < 0.001) and hepatic damage (p = 0.005) may be associated with higher incidence of ESKD, while receiving anti-HBV therapy may reduce the risk (p = 0.004).

HBsAg+ individuals may have a higher absolute long-term kidney failure risk and mortality after living donor nephrectomy. These findings might improve donation-attributable risk estimates and add new information to the utilization and management of live donors with HBV infection.