Transplanting Organs From Hepatitis B Positive Donors: Is It Safe? Is It Ethical?

Nadeem Anwar; Kenneth E. Sherman


J Viral Hepat. 2018;25(10):1110-1115. 

In This Article

Abstract and Introduction


Liver transplant centres throughout the USA face a huge shortage of liver organs for their wait-listed patients. Various types of innovations are being considered for expansion of this donor pool. Organs that were previously deemed to be high risk are now being considered for transplantation. For the last 25 years, hepatitis B core antibody (anti-HBc+) organs have been used for liver transplantation. While the initial transplantations did reveal a high incidence of de novo hepatitis (DNH) in the recipients, the medical knowledge and experience have evolved and this risk has been markedly decreased. In this paper, medical literature evaluating the safety of such organ transplants has been reviewed. There is strong evidence to suggest that using anti-HBc+ organs with appropriate prophylaxis after transplant is a safe practice with good patient and graft survivals. In the second half of the paper, we discuss whether it is ethical to use anti-HBc+ organs. We argue that the use of such organs is in compliance with the principles of medical ethics and that society at large benefits from the use of these organs. Hence, we recommend that the use of such organs is both safe and ethical and this practice should be continued in the future.


Irrespective of the etiology of liver disease, the definitive treatment for advanced or decompensated liver disease is liver transplantation. The procedure gives patients a reasonable chance of improving the quality of their life as well as an opportunity to become productive members of society again. Last year 8082 liver transplant surgeries were performed based on the current UNOS database (367 were living donations and the rest were deceased donor transplants). At this time, there are 14 232 patients listed for the procedure in the USA. The same database reports that in 2017, a total of 8740 liver organs were procured (deceased donors as well as living donors).[1] The number of donations has remained quite flat in the last 10 years. In 2017, about 10% of patients on the wait list were removed from the wait list as they became too sick for transplant. Another 10% died while waiting for an organ to become available. Transplant programs throughout the country are looking at innovative ways to increase the availability and/or utility of organs being procured for liver transplantation. Choices include living-related donor sourcing, split shared organs, as well as considering organs that were previously being underutilized due to concerns about suitability for transplantation. These organs include those procured after cardiac death, fatty livers, organs from donors greater than 50 years of age, as well as those termed as Public Health Service (PHS) high-risk organs, namely coming from donors with characteristics that could place the potential recipient at risk for transmission of HIV, HCV, and HBV infections. The PHS high-risk behaviours include people engaged in non-medical intravenous drug use in the preceding 12 months, men having had sex with men (MSM) in the preceding 12 months, professional sex workers, people having had sex with a professional sex worker, women having had sex with MSM, people having had sex with a person known or suspected to have HIV, HBV, or HCV infection in the preceding 12 months.

One type of the latter category includes organs donated from hepatitis B core antibody-positive (anti-HBc+) donors. These organs have been used for orthotopic liver transplantation (OLT) since the early days of liver transplantation but have been considered higher risk. Anti-HBc positivity could be indicative of past exposure to HBV infection, early or resolving infection (if IgM is positive), or occult HBV infection. In some cases, it represents a false-positive antibody reaction. An interpretation of various hepatitis B serologies is explained in Table 1. Once these organs are transplanted and immunosuppression instituted, there is variable risk for recipients to become HBsAg positive (reported as 16.6-87.5%).[2,3] However, in the era of nucleos(t)ide analogs combined with hepatitis B immune globulin, the incidence of post-transplantation de novo hepatitis B (DNH) has dropped and the graft and recipient survival has increased to be at par with non-anti-HBc+ organ recipients.[4] This is summarized in more detail below.