Kidney transplantation · Before the transplant
Hepatitis B or C does not close the door
Many patients are told their hepatitis rules out a transplant. For most, that has not been true for years — and the reasoning behind the refusal is often out of date.
The short answer
- Patients with hepatitis B, hepatitis C, or both can be transplanted — provided the liver is not already cirrhotic.
- Advanced liver damage is found in roughly 1% of transplant candidates. It is the exception, not the rule.
- For hepatitis B, modern antivirals and routine prophylaxis have brought long-term survival close to that of hepatitis-negative recipients.
- For hepatitis C, patients who receive a transplant have a far lower death rate than hepatitis C patients who stay on dialysis.
- If cirrhosis is present, the question changes from "kidney" to "combined liver and kidney" — which is still a transplant, not a refusal.
Why hepatitis used to be a barrier — and why it no longer is
Hepatitis remains a significant issue in dialysis populations. In countries with low prevalence, hepatitis B surface antigen (HBsAg) positivity among dialysis patients runs between 0 and 7%. In endemic regions it reaches 10 to 20%. Hepatitis C is similarly over-represented, largely because of blood transfusions and transmission within dialysis units.
For years this meant caution, and in many centres refusal. Two developments changed that: the arrival of effective antiviral drugs, and the practice of giving preventive treatment immediately after transplantation.
Long-term survival rates of hepatitis B positive recipients now approach those of hepatitis B negative recipients. What was once treated as a high-risk procedure has become routine practice.
Hepatitis B
Hepatitis B infection is not an obstacle to kidney transplantation. That is the starting position, and the exceptions are specific rather than general.
What should happen before a transplant
- Every candidate is tested for hepatitis B, whether or not there is a known history.
- If a patient is HBsAg-positive and shows markers of viral replication (HBeAg positivity and/or HBV-DNA positivity), a full liver evaluation including biopsy is required — because the risk of progressive liver disease after transplantation rises in this group.
- If active liver disease is found, it is treated before transplantation, not used as grounds for refusal.
- If cirrhosis is present, kidney transplantation alone is not appropriate. The patient should instead be evaluated for a combined liver and kidney transplant.
After the transplant
Immunosuppression can allow the virus to reactivate, which is why preventive antiviral treatment is given. Current guidelines recommend universal prophylaxis for all patients at moderate to high risk of reactivation during immunosuppression — meaning the treatment is given to everyone in the at-risk group, not only to those who show signs of trouble.
All immunosuppressive drugs can be used in hepatitis B positive transplantation. The principle is to keep total immunosuppression at the lowest workable level over the long term.
Vaccination is the single most effective action against hepatitis B, and timing matters. Patients with chronic kidney disease respond far better if vaccinated before they start dialysis — roughly 90% versus 70% immunogenicity.
If you are already on dialysis you should still be vaccinated, with an annual anti-HBs antibody titre. Below 10 IU/mL, a booster is needed. Ask when yours was last checked.
I am a hepatitis B carrier. Can I donate a kidney to my daughter?
Yes, in defined circumstances. Kidneys from hepatitis B infected donors — living or deceased — can be transplanted into recipients who are either HBsAg-positive themselves or immunised, whether that immunity came from vaccination or from past infection. Informed consent is required, and the recipient's HBsAb titre needs to be above 10.
This is not a fringe practice waiting for evidence. One of the first studies in the world on this question was carried out by our team.1
Hepatitis C
Worldwide, the World Health Organization estimates hepatitis C prevalence at around 3% — approximately 71 million people. Among kidney patients it is considerably more common.
Hepatitis C matters in transplantation because it can worsen liver damage and is a known cause of transplant glomerulopathy, new-onset diabetes after transplantation, and lymphoproliferative disorders. It can also cause chronic kidney disease in the first place, principally through membranoproliferative glomerulonephritis arising from mixed cryoglobulinemia.
None of that makes it a barrier.
The mortality rate of hepatitis C positive patients who receive a kidney transplant is markedly lower than that of hepatitis C positive patients who remain on dialysis — particularly over the first ten years after transplantation.
In other words, the risk of transplanting a hepatitis C patient has to be weighed against the risk of not transplanting them. That second risk is usually the larger one.
What should happen before a transplant
- Every candidate is tested for anti-HCV antibodies.
- Patients who are anti-HCV positive but HCV RNA negative carry a very low risk of liver disease after transplantation.
- A liver biopsy should be performed where HCV positivity is accompanied by raised transaminases. Because transaminase levels are not a reliable indicator in dialysis patients, some clinicians recommend biopsy for all hepatitis C positive candidates.
- As with hepatitis B, cirrhosis redirects the question to combined liver and kidney transplantation.
- Active chronic hepatitis is treated before transplantation.
I am hepatitis C positive. Can I donate to my son, who is negative?
This was long considered out of the question. It is now an active area of practice.
The EXPANDER-1 study at Johns Hopkins University examined exactly this: kidneys from hepatitis C infected donors transplanted into hepatitis C negative recipients, with antiviral treatment started immediately after transplantation and continued for twelve weeks, adjusted according to the donor's viral genotype.
The results, presented at the American Transplantation Congress in 2017, covered eight patients. Hepatitis C RNA was not detected in any of them after treatment, and no graft failure was observed.2,3
Kidneys from hepatitis C positive donors can also be transplanted into hepatitis C RNA positive recipients with consent. In that case, establishing the genotypes of both donor and recipient is appropriate.
So what does actually rule a patient out?
It is worth being direct about this, because vague refusals cause more harm than clear ones. In the context of hepatitis, the genuine barriers are narrow:
| Finding | What it means |
|---|---|
| Hepatitis B or C, liver not cirrhotic | Transplantation can proceed, with appropriate evaluation and prophylaxis |
| Replication markers present | Full liver evaluation including biopsy first — then decide |
| Active liver disease | Treated first, then reassessed |
| Cirrhosis | Kidney alone is not appropriate — evaluate for combined liver and kidney |
| Active hepatitis at the time of surgery | A definite contraindication until it is brought under control |
Note how narrow that last column is. Advanced liver findings occur in about 1% of potential recipients. If you have been refused, it is worth establishing which of these rows applied to you — and whether it still does.
Prof. Dr. Murat Tuncer
Nephrologist and transplant physician. Author of Kidney Transplantation — With Questions and Answers (Istanbul, 2020). His published work includes one of the first studies worldwide on kidney donation from hepatitis B surface antigen positive living donors, and the first ABO-incompatible kidney transplantations performed in Türkiye.
Refused because of hepatitis? Send us the reports
Bring us your hepatitis serology, liver function tests and any biopsy result. We will tell you honestly whether the refusal still stands under current practice — including when the answer is that it does.
Medical disclaimer. This article is general information adapted from a published book. It is not personal medical advice, it does not establish a doctor–patient relationship, and it cannot replace assessment by the physician treating you. Antiviral regimens and transplant protocols differ between centres and change over time. Always consult your own nephrologist, hepatologist or transplant centre before making decisions about your treatment.
References
- Tuncer M, Tekin S, Yucetin L, Sengul A, Demirbas A. Hepatitis B surface antigen positivity is not a contraindication for living kidney donation. Transplant Proc 2012;44(6):1628–9.
- Durand C, Brown D, Wesson R, et al. EXPANDER-1: exploring renal transplants using hepatitis C infected donors for HCV-negative recipients. Am J Transplant 2017;17(suppl 3).
- Molnar MZ, et al. Transplantation of kidneys from hepatitis C-infected donors to hepatitis C-negative recipients: single centre experience. Am J Transplant 2019;19(11):3046–57.
- Marinaki S, Kolovou K, Sakellariou S, Boletis JN, Delladetsima IK. Hepatitis B in renal transplant patients. World J Hepatol 2017;9(25):1054–63.
- Lai TS, Lee MH, Yang HI, et al. Hepatitis C viral load, genotype, and increased risk of developing end-stage renal disease: REVEAL-HCV study. Hepatology 2017;66:784–93.
