Reconsideration of HIV as a contraindication to transplantation

Clinical and Health Care Utilization Outcomes of Kidney Transplantation in HIV-Positive Recipients: A Nationwide Analysis From 2008-2013

BACKGROUND

Kidney transplantation (KTxp) provides dialysis independence, improved quality of life, and prolonged life expectancy for patients with end-stage renal disease. Before and during the early antiretroviral therapy era, KTxp was not a consideration for patients with end-stage renal disease who were HIV-positive (HIV+ve) given their short life expectancy and prevailing organ procurement constraints. Recent advancements in antiretroviral therapy and HIV care have overhauled this paradigm and KTxp has now been performed for several years, however, pragmatic studies documenting outcomes are lacking. We herein document the effectiveness of KTxp in patients who are HIV+ve by reporting clinical and health care utilization outcomes in the United States.

METHODS

Utilizing the Inpatient Databases of the Healthcare Cost & Utilization Project spanning 2008-2013, we identified all adult recipients of KTxp by procedural codes and recipients who are HIV+ve by ICD-9 codes. We extracted demographic, clinical, and resource utilization variables and compared recipients who are HIV+ve with those who are HIV-negative (HIV-ve). We then performed descriptive statistics and multivariate analysis using logistic regression to assess the effect of HIV on clinical and utilization outcomes.

RESULTS

A total of 104,137 patients had kidney transplants during the study period. Of the total, 605 patients were HIV+ve. Infections rates were similar among patients who were HIV+ve and HIV-ve (odds ratio [OR] 1.18, confidence interval [CI] 0.58-2.40; P = .652). In-hospital mortality rates were also similar (OR 0.83, CI 0.18-3.69; P = .80). Hospital charges for patients who were HIV+ve were no different from patients who were HIV-ve ($195,099 ± 1074 vs $186,567 ± 9558; P = .38).

CONCLUSION

Clinical and fiscal outcomes are comparable among patients who are HIV+ve and HIV-ve during transplant hospitalization.

Pros and cons of liver transplantation in human immunodeficiency virus infected recipients

Before the introduction of combined highly active antiretroviral therapy, a positive human immunodeficiency virus (HIV) serological status represented an absolute contraindication for solid organ transplant (SOT). The advent of highly effective combined antiretroviral therapy in 1996 largely contributed to the increased demand for SOT in HIV-positive individuals due to increased patients’ life expectancy associated with the increasing prevalence of end-stage liver disease (ESLD). Nowadays, liver failure represents a frequent cause of mortality in the HIV-infected population mainly due to coinfection with hepatitis viruses sharing the same way of transmission. Thus, liver transplantation (LT) represents a reasonable approach in HIV patients with stable infection and ESLD. Available data presently supports with good evidence the practice of LT in the HIV-positive population. Thus, the issue is no longer “whether it is correct to transplant HIV-infected patients”, but “who are the patients who can be safely transplanted” and “when is the best time to perform LT”. Indeed, the benefits of LT in HIV-infected patients, especially in terms of mid- and long-term patient and graft survivals, are strictly related to the patients’ selection and to the correct timing for transplantation, especially when hepatitis C virus coinfection is present. Aim of this article is to review the pros and cons of LT in the cohort of HIV infected recipients.

Determinants of transplant surgeons' willingness to provide organs to patients infected with HBV, HCV or HIV

The common provision of organs to patients infected with hepatitis B virus (HBV) and hepatitis C virus (HCV), but not to those infected with human immunodeficiency virus (HIV), has been attributed to perceived or real differences in transplantation efficacy among these populations. However, other explanations remain possible. We surveyed all active U.S. transplant surgeons to identify determinants of their views of the propriety of transplantation among HBV-, HCV-, and HIV-infected patients. The 347 surgeons (56.1%) returning completed questionnaires believed that HCV- and HIV-infected patients have similar post-transplant survival (p = 0.9), but that both groups fare worse than HBV-infected patients (p < 0.00001 for both comparisons). Most transplant surgeons considered HBV- and HCV-infected patients to be appropriate transplantation candidates (p = 1.0 for this comparison), whereas one-third considered HIV-infected patients to be appropriate candidates (p < 0.00001 when compared with HBV- or HCV-infected patients). That surgeons are generally willing to transplant HCV-infected patients but not HIV-infected patients, and yet believe these groups will have similar post-transplant survival, suggests that survival estimates alone do not explain surgeons' choices. HIV-infected patients should have equal access to organs unless or until evidence emerges that they fare substantially worse than other potential recipients.

Trasplante renal en pacientes infectados por el VIH

The prevalence of human immunodeficience virus (HIV) infection among patients under renal replacement therapy varies, with estimates of 1% for Europe and 1.5% for the United States. Survival in HIV infected individuals receiving renal replacement therapy has improved since the introduction of high activity antiretroviral therapy (HAART). Current experience in renal transplantation in HIV-infected patients in the United States indicates that the three-year survival rate is similar to that of HIV-negative transplant recipients, with virological and immunological control of the infection by HAART and no increase in the number of opportunistic infections or tumors. The criteria for selecting renal transplantation candidates in this population are the following: no aids-defining events, CD4 cells > 200 cells/.l and undetectable viral load under HAART. In Spain, where most of these patients are former drug abusers, a two-year period of abstinence from cocaine and heroine abuse is also required, although patients can be participating in the methadone program. The main problems in the post-transplantation period have been interactions between HAART and immunosuppressive drugs, management of hepatitis C virus (HCV) coinfection and the high rate of acute rejection. To date, seven such renal transplantations have been performed in Spain, with favorable patient and graft survival and no progression to aids.

Outcomes of liver transplantation in HIV-infected individuals: the impact of HCV and HBV infection

Liver transplantation (LT) in human immunodeficiency virus (HIV)-positive individuals is considered to be an experimental therapy with limited reported worldwide experience, and little long-term survival data. Published data suggest that the short-term outcome is encouraging in selected patients. Here, we report our experience in 14 HIV-infected liver allograft recipients, and compare outcomes between those coinfected with hepatitis C virus (HCV) and the non-HCV group. A total of 14 HIV-infected patients (12 male, 2 female, age range 26-59 years) underwent LT between January 1995 and April 2003. Indications for LT were HCV (n = 7), hepatitis B virus (HBV; n = 4), alcohol-induced liver disease (n = 2), and seronegative hepatitis (n = 1); 3 patients presented with acute liver failure. At LT, CD4 cell counts (T-helper cells that are targets for HIV) ranged from 124 to 500 cells/microL (mean 264), and HIV viral loads from <50 to 197,000 copies/mL. Nine of 12 patients were exposed to highly active antiretroviral therapy (HAART) before LT. In the non-HCV group (n = 7), all patients are alive, all surviving more than 365 days (range 668-2,661 days). No patient has experienced HBV recurrence, and graft function is normal in all 7 patients. However, 5 of 7 HCV-infected patients died after LT at 95-784 days (median 161 days). A total of 4 patients died of complications due to recurrent HCV infection and sepsis, despite antiviral therapy in 3 of them. A total of 3 patients experienced complications relating to HAART therapy. In conclusion, outcome of LT in HIV-infected patients with HBV or other causes of chronic liver disease indicates that LT is an acceptable therapeutic option in selected patients. However, longer follow-up in larger series is required before a conclusive directive can be provided for HCV / HIV coinfected patients requiring LT.