The risk of HBV reactivation after solid organ transplantation and the strategies to prevent it are not well defined.

We reviewed patients who received liver, kidney, pancreas, or heart transplants at our center between September 2015 and November 2020. We collected recipient and donor data on HBV serologies, prophylactic strategies, and known risk factors that associate with HBV reactivation in post-transplant patients.

In the study period, 2126 solid organs were transplanted into 1951 patients. The recipient (R), donor (D), or both were HBcAb(+)/HBsAg(-) in 360 transplants. Post-transplant HBV DNA developed in 0/10 heart, 0/3 pancreas-kidney, 2/1517 (0.1 %) kidney, and 10/430 (2.3 %) liver recipients. Both kidney recipients with HBV DNA tested negative on re-testing without treatment. HBV DNA developed in 17.5 % of liver recipients who were D+/R- for HBcAb (10/57). All 10 liver recipients developing HBV DNA received prophylaxis. 5 patients developed detectable HBV DNA while on prophylaxis at a median 886 days (range 139 to 2287) after transplant. 5 patients developed HBV DNA after prophylaxis was discontinued at a median 955 days (range 756 to 2003) after transplant and 596 days (395 to 1638) after discontinuation.

HBcAb is found in a significant portion of our solid organ transplant donors and recipients, and HBcAb(+)/HBsAg(-) liver allografts represent the primary risk factor for HBV post-transplant. HBV infection in non-liver solid organ transplant is minimal risk using current monitoring strategies. Infection can occur long after the transplant event. Monitoring and prophylaxis strategies in this group should be reassessed.