Transplantation of HIV-positive Patients
Transplantation of HIV-positive Patients
What are the current recommendations regarding people who are HIV positive receiving kidney or liver transplantation?
The presence of HIV in a patient has historically been considered a contraindication to transplantation because of the following concerns: (1) a stable HIV-positive candidate will immunologically decompensate with immunosuppression; (2) the viral load will increase and/or immunosuppression may enhance HIV mutations; (3) the pharmacokinetics and pharmacointeractions of antiretroviral agents and immunosuppression may lead to subtherapeutic effects or toxicity; and (4) the public perception of offering transplantation to HIV-positive patients will lead to diminished support for donation. Limited experience prior to now suggested that organ transplantation is effective in selected HIV-positive patients. However, several key papers have been recently published on the topic of organ transplantation in HIV-positive patients, as well as important clinical research developments.
In the paper by Macias and colleagues, the changing impact of HCV-related liver disease in HIV-positive patients is highlighted. In this study, 492 patients were treated with highly active antiretroviral therapy (HAART) with a mean follow-up of 4 years. Hepatitis C virus (HCV) infection was present in 323 (68%). Mortality attributable to AIDS decreased from 4.5 to 1.8 per 100 persons per year. Mortality due to liver failure increased from 0.3 to 0.5 per 100 persons per year (P < .01). The survival of patients with and without HCV infection was similar (P = .8). Although liver failure is an increasing cause of death among HIV-infected patients receiving HAART, HCV infection still has no impact on the survival of HIV-infected patients.
In the single-center report by Stock and colleagues, 14 HIV-positive patients undergoing kidney (n = 10) and liver (n = 4) transplantation are described. The rate of rejection in the kidney transplant recipients was 50%, although serum creatinine levels were normal in 8 of 10 patients, and all patients survived. Three of 4 liver transplant recipients are alive; the single death was in a patient with recurrent HCV.
The combined early experience of liver transplantation in HIV-positive patients at the University of Miami (n = 6) and the University of Pittsburgh (n = 10) is described by Neff and associates. Fourteen patients were alive at the time of publication. Six patients (38%) experienced acute cellular rejection immediately after liver transplantation. Patient and graft survival rates were similar to those seen with non-HIV-positive patients suffering from the same indications for liver transplantation.
The early experience at the King's College in the United Kingdom in 5 HIV-positive liver transplant recipients is described by Prachalias and associates. The outcomes in patients undergoing liver transplantation for hepatitis B virus indications was good in 2 patients, but outcomes were poor in the 3 patients with HCV indications. However, these experiences were in the early phases of their overall experience, raising the question of a learning curve.
And finally, the ethical and clinical rationale for a newly funded, multicenter NIH study on the utility of transplanting HIV-positive kidney and liver transplant patients is described by Roland and colleagues.
What are the current recommendations regarding people who are HIV positive receiving kidney or liver transplantation?
The presence of HIV in a patient has historically been considered a contraindication to transplantation because of the following concerns: (1) a stable HIV-positive candidate will immunologically decompensate with immunosuppression; (2) the viral load will increase and/or immunosuppression may enhance HIV mutations; (3) the pharmacokinetics and pharmacointeractions of antiretroviral agents and immunosuppression may lead to subtherapeutic effects or toxicity; and (4) the public perception of offering transplantation to HIV-positive patients will lead to diminished support for donation. Limited experience prior to now suggested that organ transplantation is effective in selected HIV-positive patients. However, several key papers have been recently published on the topic of organ transplantation in HIV-positive patients, as well as important clinical research developments.
In the paper by Macias and colleagues, the changing impact of HCV-related liver disease in HIV-positive patients is highlighted. In this study, 492 patients were treated with highly active antiretroviral therapy (HAART) with a mean follow-up of 4 years. Hepatitis C virus (HCV) infection was present in 323 (68%). Mortality attributable to AIDS decreased from 4.5 to 1.8 per 100 persons per year. Mortality due to liver failure increased from 0.3 to 0.5 per 100 persons per year (P < .01). The survival of patients with and without HCV infection was similar (P = .8). Although liver failure is an increasing cause of death among HIV-infected patients receiving HAART, HCV infection still has no impact on the survival of HIV-infected patients.
In the single-center report by Stock and colleagues, 14 HIV-positive patients undergoing kidney (n = 10) and liver (n = 4) transplantation are described. The rate of rejection in the kidney transplant recipients was 50%, although serum creatinine levels were normal in 8 of 10 patients, and all patients survived. Three of 4 liver transplant recipients are alive; the single death was in a patient with recurrent HCV.
The combined early experience of liver transplantation in HIV-positive patients at the University of Miami (n = 6) and the University of Pittsburgh (n = 10) is described by Neff and associates. Fourteen patients were alive at the time of publication. Six patients (38%) experienced acute cellular rejection immediately after liver transplantation. Patient and graft survival rates were similar to those seen with non-HIV-positive patients suffering from the same indications for liver transplantation.
The early experience at the King's College in the United Kingdom in 5 HIV-positive liver transplant recipients is described by Prachalias and associates. The outcomes in patients undergoing liver transplantation for hepatitis B virus indications was good in 2 patients, but outcomes were poor in the 3 patients with HCV indications. However, these experiences were in the early phases of their overall experience, raising the question of a learning curve.
And finally, the ethical and clinical rationale for a newly funded, multicenter NIH study on the utility of transplanting HIV-positive kidney and liver transplant patients is described by Roland and colleagues.
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