The use of serum anti-hepatitis B core antibody (HBc)–positive/hepatitis B surface antigen (HBsAg)-negative liver donors for patients with hepatitis B virus (HBV)–related liver disease (HBRLD) is a promising means of expanding the organ donor pool and does not increase the risk of HBV recurrence. However, whether such donors will compromise the histology of the liver grafts is unclear.

Among 84 patients who underwent transplantation for HBRLD and who did not have post-transplant HBV recurrence (non-detectable serum HBsAg and HBV DNA), 19 underwent liver biopsy (eight received anti-HBc–positive/HBsAg-negative liver grafts; 11 received anti-HBc–negative liver grafts) and were included in the study. Intrahepatic total HBV DNA and covalently closed circular DNA (cccDNA) were detected using real-time polymerase chain reaction; histological characteristics were evaluated with the Batts–Ludwig semi-quantitative scoring system.

Of the 19 recipients, nine (47.4%) were positive for intrahepatic HBV DNA; 82.5% (7/8) received grafts from anti-HBc–positive donors and 18.2% (2/11) received grafts from anti-HBc–negative donors (P=0.003). HBV cccDNA was not detectable in the liver grafts of the 19 recipients. Ten patients had mild inflammation and minimal fibrosis in the portal area: four of the eight in the anti-HBc–positive group and six of the 11 in the anti-HBc–negative group (P>0.05).

Anti-HBc–positive/HBsAg-negative donors for HBRLD pose a higher risk of occult HBV infection post-liver transplant but do not cause liver damage. Thus, anti-HBc–positive grafts may be considered an effective and safe means of expanding the pool of liver donors for patients with HBRLD.