The scarcity of liver donors requires consideration of grafts from sources not previously used. Allografts from
hepatitis B surface antigen (
HBsAg)-carriers without a significant
liver disease have been proposed for
liver transplant recipients with hepatitis B virus (HBV)-related
cirrhosis and
hepatocellular carcinoma (HCC). Combination prophylaxis schemes against HBV post-
liver transplantation (LT) recurrence are currently available; the efficacy of those schemes in HBV-related
cirrhosis and HCC must be assessed. This report describes the allocation of
HBsAg-positive grafts in three
HBsAg-positive recipients, with HBV-related
cirrhosis and evolving HCC lesions, two of them with hepatitis Delta virus (HDV)
coinfection. Patients were administered anti-
hepatitis B immunoglobulins (HBIGs) and
lamivudine in order to prevent HBV recurrence. In spite of anti-HBV prophylaxis, HBV
infection did persist after LT in all patients (no serum clearance of
HBsAg). HBV replication assessed by serum HBV
deoxyribonucleic acid (
DNA) presence was detected in the first month after LT in the 3 recipients. A prompt HDV
reinfection with a clinical and histological pattern of
hepatitis was observed in the 2 HBV / HDV coinfected recipients. In 1 of them, an evolving
chronic hepatitis required a second LT. The non-HDV-infected patient showed an uneventful follow-up, but the lack of the neutralizing effect of HBIGs and the high risk of escape mutants forced the addition of
adefovir-dipivoxil to
lamivudine, in order to prevent viral variants and
hepatitis recurrence. In conclusion, allografts from
HBsAg-positive donors in
HBsAg-positive recipients are associated with the persistence of the
HBsAg after LT due to the failure of
HBIG prophylaxis, even if
lamivudine does inhibit virion production. This condition favors HDV replication and HDV
hepatitis recurrence in coinfected patients. The allocation of
HBsAg-positive grafts in
HBsAg-positive recipients could be justified only in recipients without HDV
coinfection and a combined prophylaxis with
lamivudine and
adefovir-dipivoxil is currently the best way to manage escape mutants in these recipients.