Introduction: The approach to transplantation in HIV+ patients has been conservative due to fear of exacerbating an immunocompromised condition. As a result, HIV+ patients with diabetes have been excluded from pancreas transplantation due to the intense immune suppression required to prevent rejection. We report long term follow up of a pilot trial with pancreas transplant in HIV+ Type I diabetic patients. 
Methods: HIV+ patients with CD4 counts >200 cells/ml, with undetectable HIV viral load on a stable anti-retroviral regimen underwent simultaneous pancreas-kidney transplant (SPK) or pancreas after kidney (PAK). Thymoglobulin (Thymo) induction (6 mg/kg) was used for all. Maintenance immunosuppression included Cyclosporine or Tacrolimus, Mycophenolate mofetil, and Pred. 
Results: The average follow up period was 60.3 mo. Thymo induction resulted in profound lymphocyte depeletion, with CD4 counts recovering to baseline after one year. Three patients were treated for pancreas rejection. There were three opportunistic infections, all BK viremia, one of which occurred in an SPK recipient following a second round of thymo for pancreas rejection. All three patients who had an opportunistic infection are still alive, and BK viremia has not had an identifiable effect on kidney function to date in these patients. Two patients died, both with functioning grafts, at 48 mo and 55 mo after transplantation. Neither death was known to be related to an infection in the recipient. One patient has restarted insulin 90 months after transplant. No surviving patients are on dialysis. 
Conclusions: Type I diabetic transplant recipients with well controlled HIV tolerate the intensive lymphocyte depleting induction therapy required for beta cell replacement. Although there have been three opportunistic infections with BK viremia, adequate prophylaxis against opportunistic infections has been largely successful in providing protection until the CD4+ counts return to baseline. Long term follow up supports well controlled HIV+ Type I diabetic patients with renal failure are good candidates for pancreas transplant.

Table 1. Pilot patient cohort

 Table 2. Patient and organ survival