Patients with HIV can safely receive kidneys from deceased HIV-positive donors, with good five-year survival rates

HIV-positive patients can safely receive kidneys from deceased HIV-infected donors, investigators from South Africa report in the February 12th edition of the New England Journal of Medicine.  Survival rates one, three and five years after transplantation were comparable to those observed in HIV-negative kidney transplant patients. HIV infection remained well controlled but infections were an important cause of death and hospitalisation.

“Our study showed that kidneys from HIV-positive deceased donors can be transplanted into carefully selected HIV-positive recipients, with the expectation that outcome would be similar to that observed in kidney transplantation programs involving high-risk patients without HIV infection,” comment the investigators. An accompanying editorial described the study’s outcomes as “impressive.”

Thanks to antiretroviral therapy many HIV-positive patients now have a near normal life expectancy. But even in the era of effective therapy, between 8% to 22% of HIV-positive patients receiving treatment have chronic kidney disease.

Glossary

contraindication

A specific situation or circumstance which means that a drug or medical procedure should not be used because it may be harmful. For example, it may be contraindicated to provide drug A to someone who is already taking drug B.

end-stage disease

Final period or phase in the course of a disease leading to a person's death.

AIDS defining condition

Any HIV-related illness included in the list of diagnostic criteria for AIDS, which in the presence of HIV infection result in an AIDS diagnosis. They include opportunistic infections and cancers that are life-threatening in a person with HIV.

treatment-naïve

A person who has never taken treatment for a condition.

first-line therapy

The regimen used when starting treatment for the first time.

Previous research suggests that HIV-positive individuals doing well on antiretroviral therapy can have good outcomes and survival rates after kidney transplantation from HIV-negative donors.

Investigators from South Africa wanted to see if HIV-positive patients with end-stage kidney disease could safely receive kidneys from deceased donors who were also HIV-positive. The study was undertaken at the transplantation centre of the Groote Schuur Hospital in Cape Town. The policy of providing HIV-infected patients with kidneys from deceased HIV-positive individuals was initiated because HIV infection was considered a contraindication for the receipt of a donated organ. Although this policy changed in 2009, investigators continued to provide HIV-positive patients with kidneys donated by HIV-positive patients who had died.  They monitored medium term survival rates in 27 patients who received kidneys between 2008 and 2014.

They kidneys were provided by 15 deceased individuals who were either HIV treatment naïve or taking first-line antiretrovirals. None had an AIDS-defining opportunistic infection or proteinuria.

To be eligible for inclusion in the study, the recipients were required to have been taking a stable antiretroviral regimen for at least three months with an undetectable viral load and CD4 cell count of at least 200 cells/mm3. Follow-up was for a median of 2.4 years.

Two patients experienced graft failure within the first two weeks of transplantation. But the other 25 individuals had well-functioning replacement kidneys after one year. Survival rates one, three and five years after transplantation were 84%, 84% and 75%, respectively. The graft survival rate was 95% at year one, decreasing to 84% at years three and five. These outcomes were comparable to those seen in HIV-negative patients who received donated kidneys at the same unit.

There were eight cases of graft rejection, six of which were reversed with appropriate immunosuppressive therapy. Five patients died after transplantation. Infections were the principal cause.

“Opportunistic infection remains a major cause of complications and death in patients who have received a transplant,” note the authors. There were also numerous hospitalisations due to infections, but these were successfully treated.

Median CD4 cell count decreased to a 179 cells/mm3 after one year of follow-up, a decline the authors attributed to the use of immunosuppressive therapies. However, there was then a slow increase with counts reaching a median of 386/mm3 after three years. All the patients maintained an undetectable viral load. This shows that interactions between anti-HIV and immunosuppressive drugs can be successfully managed. Moreover, it also suggests that the use of donated organs from individuals with HIV does not involve a risk of superinfection with drug-resistant strains of virus.

The authors of an editorial that accompanies the study believe the findings go a long way to allaying fears about the safety of using organs from deceased HIV-positive donors in HIV-positive recipients. They conclude, “these transplantations now appear to be not only feasible but also, in fact, desirable for many patients.”

References

Muller E et al. HIV-positive-to-HIV-positive transplantation – results at 3 to 5 years. N Eng J Med 372: 613-20, 2015

Ingelfinger RR et al. The HIV-positive transplant donor – change born of necessity. N Eng J Med 372: 663-65, 2015.