To the Editor:

A 63‐year‐old man presented with hypoxemic respiratory failure secondary to newly diagnosed idiopathic pulmonary fibrosis. Three weeks after his initial presentation, a compatible but increased risk donor with positive hepatitis B surface antigen (HBsAg) became available. A decision was made to accept the available lungs because the patient's clinical condition was deteriorating rapidly and the chances of survival were otherwise slim. Due to previous cardiac surgery resulting in mediastinal adhesions, a single right lung transplantation was performed. The patient received induction immunosuppression with basiliximab and maintenance with tacrolimus, mycophenolate mofetil, and low‐dose prednisone. The recipient was negative for HBsAg, hepatitis B surface antibody (anti‐HBs), and hepatitis B core antibody (anti‐HBc), with no documented immunization before transplantation. The donor had low‐level hepatitis B virus (HBV) DNA, at 38 IU/mL, at the time of procurement and was confirmed to have negative hepatitis delta serology. The recipient received hepatitis B immunoglobulin (HBIG) immediately before and after lung transplantation daily for 7 days. Entecavir was initiated immediately after surgery. HBV serologies at 12 months after transplantation revealed positive anti‐HBc and anti‐HBs titers of 58 IU/mL, but negative HBsAg and HBV DNA. Postoperative course was complicated by slow weaning from the ventilator. The patient was discharged home 4.5 months after transplantation and his lung function remains stable with forced expiratory volume in 1 second (FEV₁) 71% of predicted at 18 months after transplantation. He will continue entecavir lifelong, and repeat HBV markers, including HBV DNA, every 6 months for the second year posttransplant.

HBV D+/R− organ transplantation is rarely considered in nonendemic regions due to limited outcome data. Chronic HBV infection is highly prevalent in Southeast Asia and Sub‐Saharan Africa, with about 350 million people chronically infected worldwide. Given the scarcity of organs and the increasing number of transplant candidates on the waiting list, expanding the donor pool to include donors with chronic HBV infection in urgent nonrenal transplant candidates must be considered.1-3 It is important to note that antiviral drugs, such as entecavir and tenofovir, are safe and effective to prevent and/or control HBV infection posttransplant. There are presently no published studies on the use of HBsAg‐positive donors in lung transplantation, and limited evidence is available in heart transplantation.1 Based on Organ Procurement and Transplantation Network (OPTN) data as of October 18, 2019, there were 23 HBV D+/R− (HBsAg‐positive‐to‐negative) transplants, 14 hearts and 9 lungs, out of 48 199 thoracic organs transplanted between February 1, 2009 and February 28, 2019; however, a total of 54 lungs from anti‐HBc‐positive and/or HBsAg‐positive donors were discarded out of a total of 2056 discarded lungs. OPTN patient survival data from HBsAg‐positive donors suggest comparable outcomes in lung transplant recipients (Figure 1).

Studies from Taiwan have reported successful heart transplantation from HBsAg‐positive donors.4-6 With appropriate antiviral and/or immunoprophylaxis in HBV‐naïve patients, no HBV‐related morbidity or mortality was encountered.6

In conclusion, the use of HBsAg‐positive donors must be considered in urgent thoracic transplantation; we demonstrate good short‐term outcome with combination of antiviral therapy and HBIG. Optimal monitoring strategies and duration of antiviral prophylaxis should be addressed in future studies.