Living donors with HBV infection are increasingly accepted to alleviate organ shortages. However, after donor nephrectomy, the impact of HBV infection on long-term kidney function remains unclear in individuals with a solitary functioning kidney.

We conducted a retrospective controlled cohort study by including 128 hepatitis B surface antigen-positive (HBsAg+) donors, and 1145 HBsAg- donors. We evaluated long-term kidney and liver function, risk of end-stage kidney diseases (ESKD), all-cause mortality, and cancer-specific mortality.

After a mean follow-up of 71.3 and 75.4 months, HBsAg+ donors demonstrated a higher increase in serum creatinine (12.1 vs 8.4 μmol/L, P<0.001) compared to HBsAg- donors. The incidence of ESKD was higher in the HBsAg+ donors (3/128 [2.3%] vs 4/1145 [0.3%], P<0.001). Stratified analyses revealed that HBeAg-positive chronic hepatitis B, abnormal liver function, and especially hepatic damage was associated with higher incidence of ESKD (P=0.004, P=0.008, P<0.001), while those receiving antiviral treatment had a lower incidence (P<0.001). Additionally, HBsAg+ donors had lower overall survival (75.5% vs 96.6%, P<0.001) and higher cancer-specific mortality (15.8% vs 0.2%, P<0.001) compared with HBsAg- donors. Sensitivity analyses after propensity score matching reported similar results.

HBsAg+ individuals may have a higher absolute long-term kidney failure risk and mortality after living donor nephrectomy. These findings might improve donation-attributable risk estimates and add new information to the utilization and management of live donors with HBV infection.