Introduction: Kidney transplantation (KT) is the definitive treatment for pediatric end-stage kidney disease, but organ shortages have led to the use of extended criteria donors, including HBV-infected donors. With proper recipient selection, pre-transplant anti-HBs assessment, optimized immunosuppression, antiviral prophylaxis, and close monitoring, the risk of HBV transmission can be minimized. While adult kidney transplant recipients show favourable outcomes with HBV core antibody-positive donors, pediatric recipients require a more cautious approach due to their higher infection risk.
Case 1: A 13year old boy with native kidney disease Nephronophthisis, received an allograft from their HBsAg-positive, IgG anti-HBc-positive mother. To mitigate the risk of HBV transmission, the recipient’s anti-HBs titer was maintained above 100 IU/L through a booster hepatitis B vaccination. As part of unit protocol, induction therapy with anti-thymocyte globulin (ATG) (2 mg/kg) was administered, followed by maintenance immunosuppression comprising tacrolimus, mycophenolate mofetil (MMF), and prednisolone. Antiviral prophylaxis with entecavir (0.5 mg daily) was initiated one day pre-transplant and continued for one year. Serial monitoring, including monthly liver function tests (LFTs) and HBV DNA PCR every three months, demonstrated no evidence of viral replication. At two years post-transplant, the recipient remains free of HBV infection, with stable graft function (eGFR 40.7 ml/min/1.73m²), normal LFTs, and no episodes of rejection.
Case 2: 14year old boy, with NKD CAKUT, received a kidney from their mother, also HBsAg-positive and IgG anti-HBc-positive, indicating chronic HBV infection. The recipient’s anti-HBs titer was >100 IU/L pre-transplant. Given an ABO-incompatible (ABOi) status, he received plasmapheresis, intravenous immunoglobulin (IVIG), and rituximab for desensitization. Basiliximab was used for induction, with tacrolimus, MMF, and prednisolone as maintenance therapy. The recipient received entecavir prophylaxis (0.5 mg daily) for one year. At 1yr 10months post-transplant, the child remains HBV-free, with normal LFTs, no rejection episodes, and an eGFR of 59.8 ml/min/1. 73m².
Conclusion: Proper donor risk assessment, recipient selection, immunosuppression, antiviral prophylaxis, and monitoring are crucial in minimizing HBV transmission in pediatric KT. These cases demonstrate that, with stringent protocols, transplantation from HBV-infected donors can be a safe and feasible option, expanding the donor pool while ensuring favourable patient outcomes.