Long-Term Clinical Outcomes of Kidney Transplantation from Hepatitis B Surface Antigen (HBsAg)-Positive Donors to HBsAg-Negative Recipients: A Systematic Review and Meta-Analysis of Real-World Studies

Background: The use of hepatitis B surface antigen-positive (HBsAg+) kidneys may expand the donor pool for transplantation. This study evaluated the incidence, risk factors, complications, organ function, and survival outcomes of transplants from HBsAg+ donors to HBsAg− recipients. Methods: A systematic search of five databases was conducted through 20 August 2023. Incidence was expressed with 95% confidence intervals (CIs); odds ratios (ORs) and hazard ratios (HRs) assessed risk factors and survival. Results: Sixteen studies were included. Donor-derived HBV infection occurred in 3.60% (21/583). Risk was higher in HBsAb-negative (OR: 6.67, 95% CI: 1.08–41.10) and HBcAb-negative recipients (OR: 12.96, 95% CI: 2.06–81.69). Abnormal liver function occurred in 35.18%, hepatitis in 3.07%, and hepatic failure in 0.84%. Liver and kidney function at 1–3 years were comparable between HBsAg+ and HBsAg− kidney recipients. Five- and ten-year graft survival (85.2%, 82.7%) and patient survival (93.0%, 91.4%) were similar to controls (p > 0.05). Conclusions: HBsAg+ kidneys can achieve acceptable long-term outcomes with appropriate antiviral prophylaxis and cautious recipient selection, though infection risk requires careful assessment. These findings supports the cautious and selective use of HBsAg-positive kidneys in appropriately selected recipients use and standardized HBV prophylaxis.