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

Background 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. Methods 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). Results 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 m 2 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 m 2 (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 m 2 . 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). Conclusions 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.