*Purpose: To explore the prevalence and risk factors of de novo HBV infection (DNH) in kidney transplantation (KT) from HBsAg⁺ donors (D[HBsAg⁺]) to HBsAg-negative recipients (R[HBsAg‾]).

*Methods: D(HBsAg⁺)/R(HBsAg‾) KTs were included consecutively between July 2017, and December 2020. Systematic search and pooled analysis were conducted to estimate the prevalence of DNH.

*Results: 81 donors were HBV DNA⁺, 12 were HBeAg⁺, and 63 received antiviral treatment before donation. 26 recipients were anti-HBs antibody (HBsAb)-negative. Lower DNH rate was observed if the donors received antiviral treatment compared to those not (4/42[9.5%] vs 0/63[0.0%], P=0.023). In 8 HBeAg⁺ donors receiving antiviral treatment, no recipient developed DNH while 1 developed in 4 HBeAg⁺ donors not. Among donors with initial HBV DNA >100IU/mL, higher DNH rate was observed if donors did not receive antiviral treatment (3/26[11.5%] vs 0/44[0%], P=0.059). Higher DNH rate was also observed in HBsAb‾ recipients compared with HBsAb⁺ recipients (0/79[0%] vs 4/26[15.3%], P=0.002). Pooled analysis included another 11 studies, showing the prevalence of DNH were 3/106[2.83%] and 1/321[0.31%] in HBsAb⁺ recipients, and 5/27[18.52%] and 1/20 [5.00%] in HBsAb‾ recipients receiving HBV DNA⁺ and HBVDNA‾/HBsAg⁺ kidneys, respectively.

*Conclusions: In D(HBsAg⁺)/R(HBsAg‾) KTs, donors’ positive HBeAg or viral loads> 100 IU/mL increased the risk of DNH, but donors’ antiviral treatment can decrease the risk. In donors with viral loads<100IU/mL, kidneys can be safely transplanted into HBsAb⁺ recipients without donors’ antiviral treatment.

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