Use of HCV-Positive Donors for Pancreas Transplantation?

Francis Leo Delmonico, MD

Disclosures

April 15, 2002

Question

Is it justified to select HCV-positive donors for pancreas transplantation?

Response from Francis Leo Delmonico, MD

I am presuming the following information to be understood in my reply to the question:

  • That the potential pancreas transplant recipient is an insulin-dependent diabetic;

  • That the candidate has end-stage renal failure and is in need of a simultaneous kidney transplant or that the candidate has undergone a successful kidney transplant; and

  • That the patient is not a candidate for islet cell transplantation.

The objective of transplanting the whole pancreas is to provide a sufficient quantity of islets to resolve the diabetic's exogenous requirement of insulin. The success of whole pancreas transplantation currently is more predictable than islet cell transplantation because only 1 pancreas is necessary to provide the necessary number of islets.[1] In contrast, multiple islet injections may be necessary from more than 1 cadaver donor.[2]

In New England, a cadaver donor whose serology screen is positive for HCV reactive antibody is excluded as an islet cell donor. Given the current method of depositing the islet cell preparation into the liver, this restriction of simultaneously introducing HCV into the liver is appropriate. HCV resides in extrahepatic tissue, including the pancreas.[3]

The timing of the whole pancreas transplant in relation to kidney transplantation is by the following consideration: not to undertake a regimen of immunosuppression that replaces the administration of exogenous insulin with a regimen of immunosuppression. The concomitant use of immunosuppression for a kidney transplant justifies the risk of immunosuppression and its complications in preventing the rejection of the pancreas.

Thus, the basis of the question "Is it justified to select HCV-positive donors for pancreas transplantation?" can be answered in part by the risk associated with the transplantation of the kidney and pancreas either simultaneously or sequentially.

For the kidney transplant recipient alone, the transplant of a kidney from an HCV-positive donor may be done in selected circumstances, especially for recipients who are HCV-positive.[4,5] Perhaps candidates for either a simultaneous kidney/pancreas transplant or a pancreas transplant after kidney and who are HCV-positive could be considered for pancreas transplants from HCV-positive donors. There is the risk of either viral reactivation or a primary infection with a different strain of HCV.[5]

There is no substantial experience with either of these scenarios reported in the literature. There is 1 retrospective 1997 report of 137 kidney-pancreas transplant recipients that concludes that HCV infection in kidney-pancreas transplant patients results in a significantly increased risk of kidney allograft failure and death.[6] A more current experience with pancreas transplantation in HCV-positive recipients is to be reported in Clinical Transplantation in the near future (personal communication, Robert Stratta, MD).

Otherwise, I would suggest that the transplant of a whole pancreas from an HCV-positive donor to an HCV-negative recipient has no more justification than what is currently a contraindication for the transplantation of islets from an HCV-positive donor.

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