Should hepatitis C positive donors be accepted for renal transplantation?

Kidney Transplantation From Hepatitis C Virus–Positive Donors Into Hepatitis C Virus–Positive Recipients: A Safe Way to Expand the Donor Pool?

INTRODUCTION

Because the disparity between the number of patients waiting for kidney transplants and the number of available cadaveric renal allografts continues to increase, there is a clear need to review the inclusion criteria for cadaveric donors.

PATIENTS AND METHODS

From January 2001 to March 2004, 24 patients with end-stage renal disease and hepatitis C virus (HCV) seropositivity underwent a kidney transplantation. In 10 transplants in HCV-positive recipients, the donor was HCV-positive (D+/R+) and in 14 cases the donor (1 living donor) was HCV-negative (D-/R+).

RESULTS

Two of 3 HCV-RNA-negative recipients who received a HCV-RNA+ kidney became HCV-RNA+ in the posttransplantation period. There was a low rate of acute rejection (8.3%). One D+/R+ patient experienced an acute vascular rejection, which finally resulted in graft loss, due to the resurgence of severe infectious disease. The serum creatinine levels at 6 months posttransplantation were similar in both groups. Acute liver dysfunction was observed in 1 patient. There was no death in the entire series. Graft survival was 92% and 90% for D+/R+ and D-/R+, respectively.

Shorter waiting times for hepatitis C virus seropositive recipients of cadaveric renal allografts from hepatitis C virus seropositive donors

INTRODUCTION

The purposes of this study were: 1) to analyze the early results of cadaveric renal transplantation from either hepatitis C virus seropositive (HCV+ ) or hepatitis C virus seronegative (HCV-) donors into HCV + recipients; and 2) to determine whether HCV+ patients with end-stage renal disease (ESRD) might benefit from receiving renal allografts from HCV + donors.

METHODS

From January 1997 to June 1999, 28 patients with ESRD and HCV infection underwent 29 cadaveric renal transplants. The data were reviewed retrospectively. Nineteen of the renal transplants were performed with allografts obtained from 15 HCV + donors and 10 with allografts obtained from 10 HCV- donors. The median follow-up was 16.2 months, with an average of 15.4+/-2 months.

RESULTS

Recipients of HCV + renal allografts had shorter waiting times for transplantation. On average, patients who received a kidney from HCV + donors were transplanted 9+/-3 months after being placed on the transplant list, compared to 29+/-3 months for patients who received a kidney from a HCV- donor. Shorter waiting times were noted in every blood type group. There were no significant differences in rejection episodes, infectious complications, renal function, liver function, graft survival, or patient survival.

CONCLUSIONS

The use of renal allografts from HCV + donors for HCV + recipients shortens the waiting time for these patients, with no short-term differences in renal and liver function, graft loss, or patient survival.

Expanded criteria donors: attempts to increase the renal transplant donor pool

There is a growing disparity between the demand for and the supply of kidneys for transplantation. The demographics of the donor pool are also changing. The average potential cadaveric organ donor is now more likely to be older, at greater risk for co-morbid conditions such as hypertension or viral infections, and more likely to die from cerebrovascular disease. These factors have led to an expansion of the criteria that defines the suitable organ donor. Expanded criteria donors are defined as the following: (1) at the upper and lower extremes in age; (2) having a history of hypertension or diabetes; (3) hemodynamically unstable; (4) non-heartbeating (cardiopulmonary death rather than brain death); (5) seropositive for hepatitis B or C; (6) having systemic infections; (7) having displayed high-risk social behavior for HIV infection; (8) having a history of malignancy; (9) having abnormal organ function; or (10) with renal anatomic anomalies or injuries. Use of kidneys from these "expanded criteria donors" is a two-edged sword. While they provide more organs for transplantation, the risk of suboptimal recipient outcome is increased. A rational approach to the use of each of these types of kidneys and proper selection of recipients is essential to obtain acceptable results. The article reviews the factors that have contributed to the successful transplantation of kidneys procured from expanded criteria organ donors and how these organs can be allocated most efficaciously to the appropriate recipients.

Hepatitis C virus and renal transplantation

During the past 12 months additional evidence has emerged from several studies, indicating that hepatitis C virus infection is the most important liver disease after renal transplantation. A new, severe and rare entity called fibrosing cholestatic hepatitis can lead to early liver failure, although the most important complications appeared in the long-run. Encouraging results with ribavirin have been described. Although glomerular lesions and more severe infections can appear in hepatitis C virus patients, graft and patient survival rates in most series are similar to those in hepatitis-C-negative patients. Survival is also better among hepatitis-C-positive patients after renal transplantation than in hepatitis-C-positive patients on dialysis on the waiting list for transplantation. Finally, the use of kidneys from hepatitis-C-positive donors is suggested for transplant into hepatitis C RNA positive patients matching the hepatitis C genotype.