Use of hepatitis B core antibody-positive donors for liver transplantation.

1. Livers from donors previously exposed to hepatitis B virus (HBV) can fail after transplantation as a result of severe HBV reactivation in the transplant recipient. 2. Antibody against hepatitis B core antigen (HBcAb) in the donor is a marker for risk for transmission of HBV and reactivation after liver transplantation. 3. Recipient HBcAb positivity and antibody to hepatitis B surface antigen (HBsAb) positivity are associated with less risk for HBV reactivation. Conversely, the absence of HBcAb and/or HBsAb in the transplant recipient, higher Child-Pugh score, and presence of HBV DNA in the donor liver may be risk factors for HBV reactivation in the transplant recipient. 4. Recipients of HBcAb-positive (HBcAb(+)) livers at high risk for HBV reactivation should be treated prophylactically with lamivudine alone or a combination of hepatitis B immunoglobulin (HBIg) and lamivudine. The value of monoprophylaxis with HBIg has not been established in this setting. 5. Until data from larger studies are available, for low-risk recipients of HBcAb(+) livers, no prophylaxis, with very close serological and virological monitoring, appears to be a potential alternative to lamivudine monoprophylaxis. 6. Recipients of HBcAb-negative livers should be investigated for HBV infection when an episode of allograft dysfunction is not readily explained by the usual causes (rejection, ischemia, or hepatitis C recurrence).