Are we ready for marginal hepatitis B core antibody-positive living liver donors?

In -summary, rapid proliferation of adult-to-adult LDLT programs in the United States and abroad during the past 5 years has created substantial concern regarding donor safety. 8,9 However, adult-to-adult LDLT provides a novel opportunity to study and improve the science of liver transplantation in ways that are not feasible with cadaveric liver transplantation. In addition to identifying essential factors involved in liver regeneration, the LDLT model allows us to conduct unique natural history studies of primary viral infection in newly transplanted grafts in a controlled prospective manner. At this time, we believe that US transplant programs offering adult-to-adult LDLT should err to the side of donor and recipient safety and exclude marginal living liver donors who may be at increased risk for having poor outcomes (i.e., older donors, steatotic donors) and those associated with potentially inferior recipient outcomes (i.e., HBcAb+ donors). Future studies of HBcAb+ adult living liver transplant donors should include protocolized collection of serum, peripheral-blood mononuclear cells, and frozen liver tissue before and periodically after donation for several years. It appears reasonable to target HBcAb+ adult living donor livers to either HBsAg+ or seropositive recipients to minimize the impact of potential HBV transmission. Last, serum, peripheral-blood mononuclear cells, and frozen liver tissue samples also should be collected prospectively in recipients of HBcAb+ living liver grafts to determine the natural history of potential HBV transmission in conjunction with antiviral and HBIG immunoprophylaxis. Although adult-to-adult LDLT poses significant potential risk to the donor, it also provides a unique opportunity to study disease mechanisms and physiological processes in a novel unprecedented manner.