KIDNEY TRANSPLANTATION FOR END STAGE RENAL FAILURE IN LIVER TRANSPLANT RECIPIENTS CARRIERS OF HEPATITIS C VIRUS

Abstract

576 AIM: Hepatitis C virus (HCV) infection in liver transplant(LTx) recipients has remained a major problem for which there is no effective treatment. Augmentation of immunosuppression is known to allow rapid multiplication of the virus, and there is evidence to suggest that the quantitative increase in viral load relates to hepatic allograft dysfunction. This has raised concerns regarding kidney transplantation (KTx) in this patient population. The purpose of this study was to examine the outcome of HCV infected (primary or de novo) LTx recipients who underwent KTx for end stage renal disease, in whom immunosuppression was significantly augmented.MATERIALS AND METHODS: Between 10/92 and 8/96, fourteen patients(11 men and 3 women) underwent KTx, a mean of 5.6 +/-2.6 ys (range 1.4-9.4, median 4.7) after LTx. The mean age at KTx was 49.8 +/-12.1 ys (range 22.4-64.5, median 50.5). Patients were followed for a mean of 2.5 +/-1.6 ys(range 1-5.9, mean 5.9) after KTx. In all cases, we examined HCV status of the donor, graft survival, patient survival, episodes of rejection, treatment of rejection, baseline immunosuppression before and after KTx, and changes in liver function tests (LFTs) before and after KTx. RESULTS: Nine patients (64%) are currently alive with stable liver function, eight of whom are dialysis free. There were 15 episodes of acute renal allograft rejection(AR) in 13 patients (mean 1.2/patient). One patient with multiple episodes of noncompliance had 9 episodes of AR and lost her graft. All episodes of AR were treated with an increase in baseline immunosuppression and high dose steroids. LFTs and renal function tests are shown below:Table All patients who are alive have normal and stable LFTs. Out of the five patients who expired, two died of lung cancer at 0.8 and 1.7 ys after KTx and 7 and 5.3 ys after LTx. Two other patients died with recurrent hepatitis C, 4 and 2.7 ys after KTx and 13 and 7.3 ys after LTx. One of them received a liver transplant but died because of primary nonfunction and sepsis, while the other died of combined hepatic and renal failure after refusing further treatment. One patient died of pancreatitis within one month following KTx. CONCLUSIONS: Despite a 3-4 fold increase in baseline immunosuppression in the first 1-6 months, KTx can be performed safely in HCV+ LTx recipients with end stage renal failure. The risk of deterioration in LFTs leading to hepatic allograft loss is approximately 14%, which does not appear to be any different from that seen in the HCV+ population undergoing isolated LTx. Over 85% of patients can maintain stable allograft liver function in the long term at least up to three years.