The clinical outcome of HBsAg-positive renal transplant recipients has been adversely affected by potentially fatal acute hepatitic exacerbations and chronic liver disease, in addition to the increased risk of hepatocellular carcinoma. The difficulty in predicting the evolution and severity of liver disease after kidney transplantation further confounds the management of these patients. The clinical course of HBsAg-positive renal transplant recipients can be modified favorably after nucleoside analogue therapy and quantitative HBV DNA assays have become available. The latter allow earlier detection of increased viral replication, before the onset of biochemical abnormality. We have combined serial HBV DNA monitoring with preemptive lamivudine therapy, and our results showed that this strategy markedly improved patient survival. Prolonged treatment, however, was associated with the selection of drug-resistant YMDD variants. Hepatitic flares were common after the development of drug resistance and could lead to decompensation in a small proportion of patients. With careful selection, discontinuation of antiviral treatment was feasible in 18.5% of treated subjects. While the outcome of HBsAg-positive renal allograft recipients should continue to improve with the availability of more effective antiviral agents, financial constraints and the paucity of research data could hamper the optimal adoption of recent advances into clinical practice.