*Purpose: Data on kidney transplantation (KTx) from hepatitis B surface antigen (HBsAg)+ donors to HBsAg- recipients [D(HBsAg+)/R(HBsAg-)] are limited. We aimed to report the outcomes of D(HBsAg+)/R(HBsAg-) KTx in recipients with or without hepatitis B surface antibody (HBsAb).

*Methods: Eighty-three D(HBsAg+)/R(HBsAg-) living KTx cases were retrospectively identified. Propensity matching of D(HBsAg+)/R(HBsAg-) cases with cases of KTx from hepatitis B core antibody (HBcAb)+ living donors to HBcAb- recipients [D(HBcAb+)/R(HBcAb-)] was performed. Primary endpoint was post-transplant HBsAg -→+.

*Results: Before KTx, 24 donors (28.9%) in the D(HBsAg+)/R(HBsAg-) group were hepatitis B virus (HBV) DNA+, and 20 recipients were HBsAb-. All eighty-three D(HBsAg+)/R(HBsAg-) recipients received the following HBV prophylaxis: hepatitis B immunoglobulin (HBIG) alone (21.7%); antiviral alone (49.4%); and combined HBIG and antiviral (28.9%). No D(HBcAb+)/R(HBcAb-) recipients received prophylaxis. After a median follow-up of 36 months (range 6-106) and 39 months (range 6-104) for the D(HBsAg+)/R(HBsAg-) and D(HBcAb+)/R(HBcAb-) groups, two D(HBsAg+)/R(HBsAg-) recipients with HBsAb-/HBcAb- became HBsAg+, accompanied with HBV DNA+, but none in the D(HBcAb+)/R(HBcAb-) group (P=0.477). Active liver injuries were more frequent in the D(HBsAg+)/R(HBsAg-) group (9.6% vs. 2.4%, P=0.048), while HBeAg-→+, HBeAb-→+, HBcAb-→+, liver and graft function, rejection, infection, graft loss, and death were not significantly different. In univariate analyses, pre-transplant HBsAb-/HBcAb- combination in the D(HBsAg+)/R(HBsAg-) recipients carried a significantly higher risk of HBsAg-→+, HBV DNA-→+, and death.

*Conclusions: D(HBsAg+)/R(HBsAg-) should not be an absolute contraindication to living kidney donation. Risks should be more balanced with respect to the benefits of D(HBsAg+)/R(HBsAg-) KTx in HBsAb-/HBcAb- candidates.

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