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Lee TH, Duong N, Sutha K, Simonetto DA, Paul S. Liver transplantation for people of minoritised sexual and gender identities in the USA. Lancet Gastroenterol Hepatol 2023; 8:1152-1162. [PMID: 37837981 DOI: 10.1016/s2468-1253(23)00238-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 10/16/2023]
Abstract
The number of people who report to be of minoritised sexual or gender identities in the USA, including lesbian, gay, bisexual, transgender, queer, and other sexuality-diverse and gender-diverse identities, has been increasing in the past decade. This diverse and unique population continues to experience not only health disparities but also psychosocial, economic, and legal disparities in accessing and receiving health care, including liver transplantations. As liver transplantation is life-saving for people with end-stage liver disease, understanding the factors that can affect access to and quality of liver transplantation care in people of minoritised sexual and gender identities in the USA, including differential social supports, insurance coverage, and medical and psychiatric comorbidities, is crucial. Actions, such as collecting sexual orientation and gender identity data, implementing inclusive language, recognising implicit biases, building diverse teams, providing a safer environment, and supporting further research to understand the unique health challenges are needed to ensure equitable access to high-quality liver transplantation care for people of minoritised sexual and gender identities.
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Affiliation(s)
- Tzu-Hao Lee
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Division of Abdominal Transplant, Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
| | - Nikki Duong
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Ken Sutha
- Division of Nephrology, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Sonali Paul
- Section of Gastroenterology, Hepatology, and Nutrition, Center for Liver Diseases and Transplant Institute, University of Chicago Medicine, Chicago, IL, USA
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2
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Durand CM, Martinez N, Neumann K, Benedict RC, Baker AW, Wolfe CR, Stosor V, Shetty A, Dietch ZC, Goudy L, Callegari MA, Massie AB, Brown D, Cochran W, Muzaale A, Fine D, Tobian AA, Winkler CA, Al Ammary F, Segev DL. Living kidney donors with HIV: experience and outcomes from a case series by the HOPE in Action Consortium. LANCET REGIONAL HEALTH. AMERICAS 2023; 24:100553. [PMID: 37600163 PMCID: PMC10435840 DOI: 10.1016/j.lana.2023.100553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/22/2023] [Accepted: 07/03/2023] [Indexed: 08/22/2023]
Abstract
Background Living kidney donation is possible for people living with HIV (PLWH) in the United States within research studies under the HIV Organ Policy Equity (HOPE) Act. There are concerns that donor nephrectomy may have an increased risk of end-stage renal disease (ESRD) in PLWH due to HIV-associated kidney disease and antiretroviral therapy (ART) nephrotoxicity. Here we report the first 3 cases of living kidney donors with HIV under the HOPE Act in the United States. Methods Within the HOPE in Action Multicenter Consortium, we conducted a prospective study of living kidney donors with HIV. Pre-donation, we estimated the 9-year cumulative incidence of ESRD, performed genetic testing of apolipoprotein L1 (APOL1), excluding individuals with high-risk variants, and performed pre-donation kidney biopsies (HOPE Act requirement). The primary endpoint was ≥grade 3 nephrectomy-related adverse events (AEs) in year one. Post-donation, we monitored glomerular filtration rate (measured by iohexol/Tc-99m DTPA [mGFR] or estimated with serum creatinine [eGFR]), HIV RNA, CD4 count, and ART. Findings There were three donors with two-four years of follow-up: a 35 year-old female, a 52 year-old male, and a 47 year-old male. Pre-donation 9-year estimated cumulative incidence of ESRD was 3.01, 8.01, and 7.76 per 10,000 persons, respectively. In two donors with APOL1 testing, no high-risk variants were detected. Biopsies from all three donors showed no kidney disease. Post-donation, two donors developed nephrectomy-related ≥grade 3 AEs: a medically-managed ileus and a laparoscopically-repaired incisional hernia. GFR declined from 103 to 84 mL/min/1.73 m2 at four years (mGFR) in donor 1, from 77 to 52 mL/min/1.73 m2 at three years (eGFR) in donor 2, and from 65 to 39 mL/min/1.73 m2 at two years (eGFR) in donor 3. HIV RNA remained <20 copies/mL and CD4 count remained stable in all donors. Interpretation The first three living kidney donors with HIV under the HOPE Act in the United States have had promising outcomes at two-four years, providing proof-of-concept to support living donation from PLWH to recipients with HIV. Funding National Institute of Allergy and Infectious Diseases, National Institutes of Health.
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Affiliation(s)
- Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | - Arthur W. Baker
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Cameron R. Wolfe
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Valentina Stosor
- Divisions of Infectious Diseases and Organ Transplantation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Aneesha Shetty
- Divisions of Infectious Diseases and Organ Transplantation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Zachary C. Dietch
- Divisions of Infectious Diseases and Organ Transplantation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Leah Goudy
- Divisions of Infectious Diseases and Organ Transplantation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michelle A. Callegari
- Divisions of Infectious Diseases and Organ Transplantation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Allan B. Massie
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Diane Brown
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Willa Cochran
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Abimereki Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Derek Fine
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron A.R. Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cheryl A. Winkler
- Cancer Innovation Laboratory, Center for Cancer Research, NCI and Basic Research Program, Frederick National Laboratories for Cancer Research, Frederick, MD, USA
| | - Fawaz Al Ammary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L. Segev
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
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3
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Salas J, Storm K, Durand CM. Organ Donors with Human Immunodeficiency Virus and Hepatitis C Virus: Expanding the Donor Pool. Infect Dis Clin North Am 2023:S0891-5520(23)00039-9. [PMID: 37258326 DOI: 10.1016/j.idc.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Using organs from donors with treatable infections is a strategy to increase the quality and number of organs for transplantation. For HIV, pilot studies of kidney and liver transplantation from donors with HIV to recipients with HIV demonstrate excellent early outcomes. However, the number of donors and transplants per year remains lower than projected due to several barriers. For HCV, the use of organs from donors with HCV has expanded to recipients without HCV due to safe, effective direct-acting antivirals for HCV, which are well-tolerated in transplant recipients. Studies across organ types demonstrate good outcomes and shorter wait times.
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Affiliation(s)
- Jordan Salas
- Department of Medicine, Johns Hopkins University School of Medicine, 2000 East Monument Street, Baltimore, MD 21205, USA; Department of Medicine, Oregon Health & Science University School of Medicine, 3181 Southwest Sam Jackson Park Road, Portland, OR, USA
| | - Kaitlyn Storm
- Department of Medicine, Johns Hopkins University School of Medicine, 2000 East Monument Street, Baltimore, MD 21205, USA
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, 2000 East Monument Street, Baltimore, MD 21205, USA.
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4
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Woods C, Owens G, Shelton BA, MacLennan PA, Sawinski D, Jacobson J, Locke JE. Efficacy of hope: Analysis of organ quality and availability among deceased HIV-positive donors. Transpl Infect Dis 2022; 24:e13916. [PMID: 35904220 PMCID: PMC9780158 DOI: 10.1111/tid.13916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/21/2022] [Accepted: 04/16/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Improved survival among people with human immunodeficiency virus (HIV) (PWH) has led to increased organ failure, necessitating transplantation. In 2013, the HIV Organ Policy Equity (HOPE) Act was passed, allowing PWH to donate organs to other PWH. No study has assessed organ quality and quantity among a national pool of PWH. METHODS CFAR Network of Integrated Clinical Systems (CNICS), a multicenter study capturing data on PWH, was used to identify 6504 deaths from 1999 to 2018. Exclusions included cause of death, chronic kidney disease, fibrosis-4 score ≥ 3.25, and opportunistic infection at the time of death. Donor quality was defined by HIV viremia and the kidney donor profile index (KDPI). The CDC Wonder database, which contains national death data, permitted the estimation of deaths among PWH nationally from 1999 to 2018. Assuming CNICS was representative of PWH nationally, percentages of potential donors were applied to the CDC Wonder cohort. RESULTS Within CNICS, there were 3241 (65.9%) potential kidney donors and 3536 (71.9%) potential liver donors from 1999 to 2018. Based on viremia and KDPI, 821 were lower-risk kidney donors (16.7%) and 1206 (24.5%) were lower-risk liver donors. Within CDC Wonder, we identified 12 048 potential donors from 1999 to 2018. Extrapolating from CNICS to the national cohort suggested 396 kidney donors (792 kidneys) and 433 liver donors annually, with 100 kidney donors (200 kidneys) and 147 livers being lower-risk. CONCLUSION A substantial number of PWH meet donation criteria, a valuable source of organs for PWH in need of transplants. Our estimates suggest there may be more available organs from PWH than current transplant numbers indicate.
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Affiliation(s)
| | - Grace Owens
- University of Alabama at Birmingham Heersink School of Medicine
- University of Virginia
| | | | | | | | | | - Jayme E. Locke
- University of Alabama at Birmingham Heersink School of Medicine
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5
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Predmore Z, Doby B, Bozzi DG, Durand C, Segev D, Sugarman J, Tobian AA, Wu AW. Barriers experienced by organ procurement organizations in implementing the HOPE act and HIV-positive organ donation. AIDS Care 2022; 34:1144-1150. [PMID: 34180726 PMCID: PMC8725194 DOI: 10.1080/09540121.2021.1945999] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 06/16/2021] [Indexed: 01/26/2023]
Abstract
In the seven years since the HIV Organ Policy Equity (HOPE) Act made HIV-positive organ donation to HIV-positive recipients legally permissible in the United States, there have been fewer HIV-positive organ donations than expected. Organ procurement organizations (OPOs) play a key role in the transplant system and barriers at OPOs may be partly responsible for the relatively low number of HIV-positive donors. To understand potential OPO barriers, we conducted semi-structured interviews with 20 OPO staff members. Interviews were recorded, transcribed, and analyzed using a conventional content analytic approach with two coders. OPO staff had high levels of knowledge about HOPE. Many had evaluated referrals of HIV-positive donors and approached families for authorization. Barriers to HIV-positive organ recovery identified included obtaining authorization for donation, potentially disclosing HIV status to next-of-kin, and fear of HIV infection among those engaged in organ recovery. Strategies to overcome these barriers include providing continuing education about the specific tasks required to procure organs from HIV-positive donors, implementing targeted interventions to reduce fear of infection, and developing partnerships with HIV advocacy and care organizations. Given the central role OPOs play, HIV-positive donations are unlikely to occur in significant numbers unless these barriers can be overcome.
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Affiliation(s)
- Zachary Predmore
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD
| | | | - Debra G. Bozzi
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD
| | - Christine Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeremy Sugarman
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD
| | - Aaron A.R. Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Albert W. Wu
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD
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6
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Werbel WA, Brown DM, Kusemiju OT, Doby BL, Seaman SM, Redd AD, Eby Y, Fernandez RE, Desai NM, Miller J, Bismut GA, Kirby CS, Schmidt HA, Clarke WA, Seisa M, Petropoulos CJ, Quinn TC, Florman SS, Huprikar S, Rana MM, Friedman-Moraco RJ, Mehta AK, Stock PG, Price JC, Stosor V, Mehta SG, Gilbert AJ, Elias N, Morris MI, Mehta SA, Small CB, Haidar G, Malinis M, Husson JS, Pereira MR, Gupta G, Hand J, Kirchner VA, Agarwal A, Aslam S, Blumberg EA, Wolfe CR, Myer K, Wood RP, Neidlinger N, Strell S, Shuck M, Wilkins H, Wadsworth M, Motter JD, Odim J, Segev DL, Durand CM, Tobian AAR. National Landscape of Human Immunodeficiency Virus-Positive Deceased Organ Donors in the United States. Clin Infect Dis 2022; 74:2010-2019. [PMID: 34453519 PMCID: PMC9187316 DOI: 10.1093/cid/ciab743] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Organ transplantation from donors with human immunodeficiency virus (HIV) to recipients with HIV (HIV D+/R+) presents risks of donor-derived infections. Understanding clinical, immunologic, and virologic characteristics of HIV-positive donors is critical for safety. METHODS We performed a prospective study of donors with HIV-positive and HIV false-positive (FP) test results within the HIV Organ Policy Equity (HOPE) Act in Action studies of HIV D+/R+ transplantation (ClinicalTrials.gov NCT02602262, NCT03500315, and NCT03734393). We compared clinical characteristics in HIV-positive versus FP donors. We measured CD4 T cells, HIV viral load (VL), drug resistance mutations (DRMs), coreceptor tropism, and serum antiretroviral therapy (ART) detection, using mass spectrometry in HIV-positive donors. RESULTS Between March 2016 and March 2020, 92 donors (58 HIV positive, 34 FP), representing 98.9% of all US HOPE donors during this period, donated 177 organs (131 kidneys and 46 livers). Each year the number of donors increased. The prevalence of hepatitis B (16% vs 0%), syphilis (16% vs 0%), and cytomegalovirus (CMV; 91% vs 58%) was higher in HIV-positive versus FP donors; the prevalences of hepatitis C viremia were similar (2% vs 6%). Most HIV-positive donors (71%) had a known HIV diagnosis, of whom 90% were prescribed ART and 68% had a VL <400 copies/mL. The median CD4 T-cell count (interquartile range) was 194/µL (77-331/µL), and the median CD4 T-cell percentage was 27.0% (16.8%-36.1%). Major HIV DRMs were detected in 42%, including nonnucleoside reverse-transcriptase inhibitors (33%), integrase strand transfer inhibitors (4%), and multiclass (13%). Serum ART was detected in 46% and matched ART by history. CONCLUSION The use of HIV-positive donor organs is increasing. HIV DRMs are common, yet resistance that would compromise integrase strand transfer inhibitor-based regimens is rare, which is reassuring regarding safety.
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Affiliation(s)
- William A Werbel
- Correspondence: W. A. Werbel, Department of Medicine, Johns Hopkins School of Medicine, 725 N Wolfe St, PCTB/Second Floor, Baltimore, MD 21205 ()
| | - Diane M Brown
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Oyinkansola T Kusemiju
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brianna L Doby
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shanti M Seaman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew D Redd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Yolanda Eby
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Reinaldo E Fernandez
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Niraj M Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jernelle Miller
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gilad A Bismut
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles S Kirby
- Department of Biochemistry, Cellular, and Molecular Biology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Haley A Schmidt
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William A Clarke
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael Seisa
- Laboratory Corporation of America (LabCorp), South San Francisco, California, USA
| | | | - Thomas C Quinn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Sander S Florman
- Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, New York City, New York, USA
| | - Shirish Huprikar
- Department of Medicine, Division of Infectious Diseases, The Mount Sinai Hospital, New York City, New York, USA
| | - Meenakshi M Rana
- Department of Medicine, Division of Infectious Diseases, The Mount Sinai Hospital, New York City, New York, USA
| | - Rachel J Friedman-Moraco
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Aneesh K Mehta
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Peter G Stock
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jennifer C Price
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Valentina Stosor
- Division of Infectious Disease and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Shikha G Mehta
- Section of Transplant Nephrology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Alexander J Gilbert
- MedStar Georgetown Transplant Institute, Georgetown University School of Medicine, Washington, DC, USA
| | - Nahel Elias
- Department of Surgery, Division of Transplant Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michele I Morris
- Department of Medicine, Division of Infectious Diseases, University of Miami, Miami, Florida, USA
| | - Sapna A Mehta
- New York University Langone Transplant Institute, New York University Grossman School of Medicine, New York, New York, USA
| | - Catherine B Small
- Department of Medicine, Division of Infectious Diseases, Weill Cornell Medical College, New York, New York, USA
| | - Ghady Haidar
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Maricar Malinis
- Department of Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jennifer S Husson
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Marcus R Pereira
- Department of Medicine, Division of Infectious Diseases, Columbia University Medical Center, New York, New York, USA
| | - Gaurav Gupta
- Department of Medicine, Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jonathan Hand
- Department of Infectious Diseases, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Varvara A Kirchner
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Avinash Agarwal
- Department of Surgery, Division of Transplantation, University of Virginia, Charlottesville, Virginia, USA
| | - Saima Aslam
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | - Emily A Blumberg
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cameron R Wolfe
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - R Patrick Wood
- Department of Surgery, Division of Transplantation, University of Wisconsin, Madison, Wisconsin, USA
| | - Nikole Neidlinger
- Department of Surgery, Division of Transplantation, University of Wisconsin, Madison, Wisconsin, USA
- UW Health Organ Procurement Organization, Madison, Wisconsin, USA
| | - Sara Strell
- UW Health Organ Procurement Organization, Madison, Wisconsin, USA
| | | | | | | | - Jennifer D Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonah Odim
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - HOPE in Action Investigators
PiquantDominqueLinkKatherineRNHemmersbach-MillerMarionMD, PhDPearsonThomasMDTurgeonNicoleMDLyonG MarshallMD, MMScKitchensWilliamMD PhDHuckabyJerylMSCRA, CCRCLasseterA FrancieRNElbeinRivkaRN, BSNRobersonAprilRNFerryElizabethRNKlockEthanBSCochranWilla VCRNPMorrisonMichelleBSNRasmussenSarahBABollingerJuliMSSugarmanJeremyMDSmithAngela RMBAThomasMargaretBSCoakleyMargaretRNTimponeJosephMDStuckeAlyssaBSHaydelBrandyDieterRebeccaPharmDKleinElizabeth JBANeumannHenryMDGallonLorenzoMDGoudyLeahRNCallegariMichelleMarrazzoIliseRN, BSN, MPHJacksonTowandaPruettTimothyMDFarnsworthMaryCCRCLockeJayme EMD, MPH, FACS, FASTMompoint-WilliamsDarnellCRNP, DNPBasingerKatherineRN, CCRPMekeelKristinMDNguyenPhirumBSKwanJoanneSrisengfaTabChin-HongPeterMDRogersRodneySimkinsJacquesMDMunozCarlosCRCDunnTyMDSawinskiDierdreMDSilveiraFernandaMDHughesKaileyMPHPakstisDiana LynnRN, BSN, MBANagyJamieBABaldecchiMaryMuthukumarThangamaniMDEddieMelissa DMS, RNRobbKatharineRNSalsgiverElizabethMPHWittingBrittaBSAzarMarwan MVillanuevaMerceditasFormicaRichardTomlinRicardaBS, CCRP
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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7
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Durand CM, Florman S, Motter JD, Brown D, Ostrander D, Yu S, Liang T, Werbel WA, Cameron A, Ottmann S, Hamilton JP, Redd AD, Bowring MG, Eby Y, Fernandez RE, Doby B, Labo N, Whitby D, Miley W, Friedman-Moraco R, Turgeon N, Price JC, Chin-Hong P, Stock P, Stosor V, Kirchner V, Pruett T, Wojciechowski D, Elias N, Wolfe C, Quinn TC, Odim J, Morsheimer M, Mehta SA, Rana MM, Huprikar S, Massie A, Tobian AA, Segev DL. HOPE in action: A prospective multicenter pilot study of liver transplantation from donors with HIV to recipients with HIV. Am J Transplant 2022; 22:853-864. [PMID: 34741800 PMCID: PMC9997133 DOI: 10.1111/ajt.16886] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 01/25/2023]
Abstract
Liver transplantation (LT) from donors-with-HIV to recipients-with-HIV (HIV D+/R+) is permitted under the HOPE Act. There are only three international single-case reports of HIV D+/R+ LT, each with limited follow-up. We performed a prospective multicenter pilot study comparing HIV D+/R+ to donors-without-HIV to recipients-with-HIV (HIV D-/R+) LT. We quantified patient survival, graft survival, rejection, serious adverse events (SAEs), human immunodeficiency virus (HIV) breakthrough, infections, and malignancies, using Cox and negative binomial regression with inverse probability of treatment weighting. Between March 2016-July 2019, there were 45 LTs (8 simultaneous liver-kidney) at 9 centers: 24 HIV D+/R+, 21 HIV D-/R+ (10 D- were false-positive). The median follow-up time was 23 months. Median recipient CD4 was 287 cells/µL with 100% on antiretroviral therapy; 56% were hepatitis C virus (HCV)-seropositive, 13% HCV-viremic. Weighted 1-year survival was 83.3% versus 100.0% in D+ versus D- groups (p = .04). There were no differences in one-year graft survival (96.0% vs. 100.0%), rejection (10.8% vs. 18.2%), HIV breakthrough (8% vs. 10%), or SAEs (all p > .05). HIV D+/R+ had more opportunistic infections, infectious hospitalizations, and cancer. In this multicenter pilot study of HIV D+/R+ LT, patient and graft survival were better than historical cohorts, however, a potential increase in infections and cancer merits further investigation.
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Affiliation(s)
- Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sander Florman
- Recanati-Miller Transplantation Institute, The Mount Sinai Hospital, New York, NY
| | - Jennifer D. Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Diane Brown
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Darin Ostrander
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sile Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tao Liang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William A. Werbel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shane Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - James P. Hamilton
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew D. Redd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yolanda Eby
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Nazzarena Labo
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Denise Whitby
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Wendell Miley
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | | | | | - Jennifer C. Price
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Peter Chin-Hong
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Peter Stock
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Valentina Stosor
- Divisions of Infectious Diseases and Organ Transplantation Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Cameron Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC
| | - Thomas C. Quinn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Jonah Odim
- Division of Allergy, Immunology and Transplantation, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Megan Morsheimer
- Division of Allergy, Immunology and Transplantation, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Sapna A. Mehta
- New York University Langone Transplant Institute, New York, NY
| | - Meenakshi M. Rana
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York NY
| | - Shirish Huprikar
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York NY
| | - Allan Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aaron A.R. Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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8
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An Update on Usage of High-Risk Donors in Liver Transplantation. J Clin Med 2021; 11:jcm11010215. [PMID: 35011956 PMCID: PMC8746244 DOI: 10.3390/jcm11010215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/01/2021] [Accepted: 12/28/2021] [Indexed: 12/13/2022] Open
Abstract
The ideal management for end stage liver disease, acute liver failure, and hepatocellular carcinoma (HCC), within specific criteria, is liver transplantation (LT). Over the years, there has been a steady increase in the candidates listed for LT, without a corresponding increase in the donor pool. Therefore, due to organ shortage, it has been substantially difficult to reduce waitlist mortality among patients awaiting LT. Thus, marginal donors such as elderly donors, steatotic donors, split liver, and donors after cardiac death (DCD), which were once not commonly used, are now considered. Furthermore, it is encouraging to see the passing of Acts, such as the HIV Organ Policy Equity (HOPE) Act, enabling further research and development in utilizing HIV grafts. Subsequently, the newer antivirals have aided in successful post-transplant period, especially for hepatitis C positive grafts. However, currently, there is no standardization, and protocols are center specific in the usage of marginal donors. Therefore, studies with longer follow ups are required to standardize its use.
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9
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Klitenic SB, Levan ML, Van Pilsum Rasmussen SE, Durand CM. Science Over Stigma: Lessons and Future Direction of HIV-to-HIV Transplantation. CURRENT TRANSPLANTATION REPORTS 2021; 8:314-323. [PMID: 34812403 PMCID: PMC8600909 DOI: 10.1007/s40472-021-00345-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The HIV Organ Policy Equity (HOPE) Act permits transplantation from donors-with-HIV to recipients-with-HIV (HIV D + /R +). We assess HOPE implementation, summarizing progress and challenges at clinical, legislative, and community levels. RECENT FINDINGS As of July 2021, there have been 300 kidney and 87 liver transplants within HOPE research studies in the USA. Early HIV D + /R + kidney transplant outcomes show excellent patient survival (100%) and graft survival (92%). The number of HOPE donors continues to grow annually but remains lower than projections. State-level policy restrictions are identified in 34 states; however, these do not seem to have impacted practice; 16 states have passed new legislation to facilitate HIV D + /R + transplantation. Stigma related to HIV and low donor registration rates pose additional barriers. SUMMARY Early outcomes of HOPE Act transplants are encouraging. Progress to reach full implementation and realize the full benefit of this innovation is ongoing.
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Affiliation(s)
- Samantha B. Klitenic
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Macey L. Levan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | | | - Christine M. Durand
- Department of Medicine and Oncology, Johns Hopkins University School of Medicine, 725 North Wolfe Street/PCTB 228, Baltimore, MD 21205 USA
- Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 725 North Wolfe Street, Baltimore, MD 21205 USA
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10
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Patients' Experiences With HIV-positive to HIV-positive Organ Transplantation. Transplant Direct 2021; 7:e745. [PMID: 34386582 PMCID: PMC8352618 DOI: 10.1097/txd.0000000000001197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/04/2021] [Indexed: 12/22/2022] Open
Abstract
Background. HIV+ donor (HIV D+) to HIV+ recipient (HIV R+) transplantation involves ethical considerations related to safety, consent, stigma, and privacy, which could be better understood through studying patients’ actual experiences. Methods. We interviewed kidney and liver transplant recipients enrolled in clinical trials evaluating HIV D+/R+ transplantation at 4 centers regarding their decision-making process, the informed consent process, and posttransplant experiences. Participants were interviewed at-transplant (≤3 wk after transplant), posttransplant (≥3 mo after transplant), or both time points. Interviews were analyzed thematically using constant comparison of inductive and deductive coding. Results. We conducted 35 interviews with 22 recipients (15 at-transplant; 20 posttransplant; 13 both time points; 85% participation). Participants accepted HIV D+ organs because of perceived benefits and situational factors that increased their confidence in the trials and outweighed perceived clinical and social risks. Participants reported positive experiences with the consent process and the trial. Some described HIV-related stigma and emphasized the need for privacy; others believed HIV D+/R+ transplantation could help combat such stigma. There were some indications of possible therapeutic misestimation (overestimation of benefits or underestimation of risks of a study). Some participants believed that HIV+ transplant candidates were unable to receive HIV-noninfected donor organs. Conclusions. Despite overall positive experiences, some ethical concerns remain that should be mitigated going forward. For instance, based on our findings, targeted education for HIV+ transplant candidates regarding available treatment options and for transplant teams regarding privacy and stigma concerns would be beneficial.
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11
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Fuller R, Rana MM. Advancing organ transplantation through HIV-to-HIV transplantation. Curr Opin Organ Transplant 2021; 26:419-423. [PMID: 34224501 DOI: 10.1097/mot.0000000000000892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Persons living with HIV (PLWH) have a life expectancy that is nearly equivalent to the general population, and thus are facing health conditions associated with normal aging as well as long-term HIV infection. End-organ disease is associated with significant morbidity and mortality and solid organ transplantation (SOT) may be a viable option for many PLWH. We review the history and recent updates in SOT in PLWH, specifically focusing on HIV-to-HIV transplantation. RECENT FINDINGS Following promising data out of South Africa and to expand the donor pool, the United States passed the HIV Organ Procurement Equity (HOPE) Act, allowing for HIV-to-HIV SOT. Preliminary data to date, especially in HIV-to-HIV kidney transplantation, suggest overall excellent patient and graft survival outcomes with no HIV breakthrough infection. SUMMARY Preliminary HIV D+R+ SOT data to date suggest promising patient outcomes and no significant adverse events to recipients or living donors. This is an important step in expanding the donor pool and increasing opportunity for SOT in PLWH.
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Affiliation(s)
- Risa Fuller
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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12
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Bonny TS, Kirby C, Martens C, Rose R, Desai N, Seisa M, Petropoulos C, Florman S, Friedman-Moraco RJ, Turgeon NA, Brown D, Segev DL, Durand CM, Tobian AAR, Redd AD. Outcomes of donor-derived superinfection screening in HIV-positive to HIV-positive kidney and liver transplantation: a multicentre, prospective, observational study. Lancet HIV 2020; 7:e611-e619. [PMID: 32730756 PMCID: PMC8073978 DOI: 10.1016/s2352-3018(20)30200-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/23/2020] [Accepted: 05/04/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND One of the primary risks of HIV-positive to HIV-positive organ transplantation is loss of virological control because of donor-derived HIV superinfection, which occurs when an HIV-positive individual becomes infected with a new distinct HIV strain. In this study, as part of the larger HIV Organ Policy Equity pilot study, HIV-positive to HIV-positive kidney and liver transplant recipients in the USA were examined for evidence of sustained donor-derived HIV superinfection. METHODS In this multicentre, prospective, observational study, HIV-positive to HIV-positive kidney and liver transplant recipients were followed in three hospitals in the USA. Candidates with well controlled HIV infection on ART, no active opportunistic infections, and minimum CD4 T-cell counts (>100 cells per μL for liver and >200 cells per μL for kidney per federal guidelines) were eligible to receive a kidney or liver from deceased HIV-positive donors without active infections or neoplasm. Peripheral blood mononuclear cells were collected from donor-recipient pairs at the time of transplantation, and from recipients at several timepoints up to 3 years after transplantation. Donor samples were assessed for HIV RNA viral load, CD4 cell count, and antiretroviral drug-resistant mutations. Donor and recipient HIV proviral DNA, and viral RNA from the viraemic timepoint were sequenced using a site-directed next-generation sequencing assay for the reverse transcriptase and gp41 genes. Neighbour-joining phylogenetic trees and direct sequence comparison were used to detect the presence of HIV superinfection. This study is registered with ClinicalTrials.gov, NCT02602262. FINDINGS 14 HIV-positive to HIV-positive kidney and eight liver transplant recipients were followed from March, 2016, to July, 2019. 17 recipients had adequate viral sequences allowing for HIV superinfection assessment. Eight donors were suppressed (viral load <400 copies per mL), and none had multiclass drug-resistant mutations detected. None of the recipients examined had evidence of HIV superinfection. One recipient had a viraemic episode (viral load of 2 080 000 copies per mL) 3 years after transplantation as a result of non-adherence to ART. Only recipient viral sequences were detected during the viraemic episode, suggesting that the donor virus, if present, was not reactivated despite temporary withdrawal of ART. INTERPRETATION These findings suggest that loss of HIV suppression due to donor-derived HIV superinfection might not be a significant clinical concern in carefully monitored ART suppressed HIV-positive organ recipients. FUNDING US National Institute of Allergy and Infectious Diseases and National Cancer Institute.
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Affiliation(s)
- Tania S Bonny
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles Kirby
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Craig Martens
- Genomic Unit, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT, USA
| | - Rebecca Rose
- Bioinfoexperts, Shreveport, Los Angeles, CA, USA
| | - Niraj Desai
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael Seisa
- Laboratory Corporation of America (LabCorp), South San Francisco, CA, USA
| | | | - Sander Florman
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Diane Brown
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Andrew D Redd
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; International HIV Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, MD, USA.
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13
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Katou S, Vogel T, Morgul H, Eichelmann AK, Becker F, Slepecka P, Boehmer K, Reichelt D, Reuter S, Pascher A, Suwelack B, Brockmann J. ABO-Incompatible Living Donor Kidney Transplantation in a Human Immunodeficiency Virus-Positive Recipient From a Human Immunodeficiency Virus-Positive Donor: A Case Report. Transplant Proc 2020; 52:2739-2741. [PMID: 32771247 DOI: 10.1016/j.transproceed.2020.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/11/2020] [Indexed: 11/16/2022]
Abstract
A human immunodeficiency virus (HIV) infection is no longer an absolute contraindication for solid organ transplantation, yet such a setting is still challenging and little explored because of general reservations and medical difficulties. We describe a 51-year-old man with end-stage renal failure due to polycystic kidney disease who underwent an ABO-incompatible kidney transplantation from his 49-year-old male partner. Early postoperative course revealed an episode of suspected acute rejection, which was successfully managed with a steroid pulse. Both donor and recipient continued to have an undetectable viral load after adjusting antiretroviral medication to renal function. To the best of our knowledge, this is the first report of a successful ABO-incompatible living donor kidney transplantation from an HIV-positive donor in an HIV-positive recipient, and this case seems to be a valuable approach with favorable results.
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Affiliation(s)
- Shadi Katou
- Department of General, Visceral, and Transplant Surgery, University Hospital of Muenster, Muenster.
| | - Thomas Vogel
- Department of General, Visceral, and Transplant Surgery, University Hospital of Muenster, Muenster
| | - Haluk Morgul
- Department of General, Visceral, and Transplant Surgery, University Hospital of Muenster, Muenster
| | - Ann-Kathrin Eichelmann
- Department of General, Visceral, and Transplant Surgery, University Hospital of Muenster, Muenster
| | - Felix Becker
- Department of General, Visceral, and Transplant Surgery, University Hospital of Muenster, Muenster
| | - Patrycja Slepecka
- Department of General, Visceral, and Transplant Surgery, University Hospital of Muenster, Muenster
| | | | - Doris Reichelt
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, Muenster, Germany
| | - Stefan Reuter
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, Muenster, Germany
| | - Andreas Pascher
- Department of General, Visceral, and Transplant Surgery, University Hospital of Muenster, Muenster
| | - Barbara Suwelack
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, Muenster, Germany
| | - Jens Brockmann
- Department of General, Visceral, and Transplant Surgery, University Hospital of Muenster, Muenster
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14
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The future of HIV Organ Policy Equity Act is now: the state of HIV+ to HIV+ kidney transplantation in the United States. Curr Opin Organ Transplant 2020; 24:434-440. [PMID: 31145154 DOI: 10.1097/mot.0000000000000653] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW We report the current state of HIV+ to HIV+ kidney transplantation in the United States and remaining challenges in implementing this practice nationally. RECENT FINDINGS The HIV Organ Policy Equity (HOPE) Act, which was the first step in unlocking the potential of HIV+ organ donors, mandates clinical research on HIV+ to HIV+ transplantation. As of March 2019, there have been 57 HOPE donors, including both true and false positive HOPE donors resulting in more than 120 transplants. SUMMARY The HOPE Act, signed in 2013, reversed the federal ban on the transplantation of organs from HIV+ donors into HIV+ recipients. Ongoing national studies are exploring the safety, feasibility, and efficacy of both kidney and liver transplantation in this population. If successfully and fully implemented, HIV+ to HIV+ transplantation could attenuate the organ shortage for everyone waiting, resulting in a far-reaching public health impact.
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15
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Crismale JF, Ahmad J. Expanding the donor pool: Hepatitis C, hepatitis B and human immunodeficiency virus-positive donors in liver transplantation. World J Gastroenterol 2019; 25:6799-6812. [PMID: 31885421 PMCID: PMC6931007 DOI: 10.3748/wjg.v25.i47.6799] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 11/26/2019] [Accepted: 11/29/2019] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) remains the best option for patients with end-stage liver disease but the demand for organs from deceased donors continues to outweigh the available supply. The advent of highly effective anti-viral treatments has reduced the number of patients undergoing LT for hepatitis C (HCV) and hepatitis B (HBV) related liver disease and yet the number of patients waiting for LT continues to increase, driven by an increase in the patients listed with a diagnosis of cirrhosis due to non-alcoholic steatohepatitis and alcohol-related liver disease. In addition, human immunodeficiency virus (HIV) infection, which was previously a contra-indication for LT, is no longer a fatal disease due to the effectiveness of HIV therapy and patients with HIV and liver disease are now developing indications for LT. The rising demand for LT is projected to increase further in the future, thus driving the need to investigate potential means of expanding the pool of potential donors. One mechanism for doing so is utilizing organs from donors that previously would have been discarded or used only in exceptional circumstances such as HCV-positive, HBV-positive, and HIV-positive donors. The advent of highly effective anti-viral therapy has meant that these organs can now be used with excellent outcomes in HCV, HBV or HIV infected recipients and in some cases uninfected recipients.
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Affiliation(s)
- James F Crismale
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Jawad Ahmad
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
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16
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Kulkarni HS, Korenblat KM, Kreisel D. Expanding the donor pool for lung transplantation using HCV-positive donors. J Thorac Dis 2019; 11:S1942-S1946. [PMID: 31632793 DOI: 10.21037/jtd.2019.08.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Hrishikesh S Kulkarni
- Divisions of Pulmonary and Critical Care Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Kevin M Korenblat
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
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17
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Wilk AR, Hunter RA, McBride MA, Klassen DK. National landscape of HIV+ to HIV+ kidney and liver transplantation in the United States. Am J Transplant 2019; 19:2594-2605. [PMID: 31207040 DOI: 10.1111/ajt.15494] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 04/21/2019] [Accepted: 05/15/2019] [Indexed: 01/25/2023]
Abstract
The HIV Organ Policy Equity (HOPE) Act, enacted on November 21, 2013, enables research on the transplantation of organs from donors infected with human immunodeficiency virus (HIV) (HIV+) into HIV+ individuals who, prior to transplantation, are infected with HIV. In 2015, the Organ Procurement and Transplantation Network revised organ allocation policies on November 21, and on November 23, the Secretary of Health and Human Services published research criteria and revised the Final Rule accordingly. The HOPE Act appears to be underutilized to date. As of December 31, 2018, there were 56 donors recovered (50 donors transplanted) resulting in 102 organs transplanted (31 liver, 71 kidney). As of December 31, 2018, 212 registrations were indicated on the waiting list as willing to accept an HIV+ kidney or liver, most of which were waiting in active status. Due to the limited number of transplants performed to date, definitive safety conclusions cannot be reached at this time, though current data suggest that 1-year patient and graft survival does not deviate in a major way from that observed in HIV+ recipients of non-HIV+ organs or non-HIV+ recipients. As safety data are reviewed and disseminated, it is anticipated that HOPE participation will increase should safety signals remain low.
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Affiliation(s)
- Amber R Wilk
- Research Department, United Network for Organ Sharing, Richmond, Virginia
| | - Robert A Hunter
- Policy and Community Relations Department, United Network for Organ Sharing, Richmond, Virginia
| | - Maureen A McBride
- Contract Operations, United Network for Organ Sharing, Richmond, Virginia
| | - David K Klassen
- Office of the Chief Medical Officer, United Network for Organ Sharing, Richmond, Virginia
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18
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Bollinger J, Eno A. Early experiences of independent advocates for potential HIV+ recipients of HIV+ donor organ transplants. Clin Transplant 2019; 33:e13617. [PMID: 31140611 PMCID: PMC6779050 DOI: 10.1111/ctr.13617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/30/2019] [Accepted: 05/23/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND HIV+ to HIV+ solid organ transplants in the United States are now legally permitted. Currently, these transplants must adhere to the HIV Organ Policy Equity (HOPE) Act Safeguards and Research Criteria that require the provision of an independent recipient advocate, a novel requirement for solid organ transplant programs. The objective of this study was to understand the experiences of the first advocates serving in this role. METHODS We conducted semi-structured interviews with 15 HOPE independent recipient advocates (HIRAs) from 12 institutions. RESULTS All HIRAs had a professional degree and experience in transplantation or infectious diseases. HIRAs' encounters with potential recipients varied in length, modality, and timing. The newness of the role and the lack of guidance were associated with unease among some HIRAs. Some questioned whether their role was redundant to others involved in transplantation and research since some potential recipients experienced informational fatigue. CONCLUSIONS HOPE independent recipient advocates are ensuring the voluntariness of potential participants' decision to accept an HIV-infected organ. Many suggested additional guidance would be helpful and alleviate unease. Concerns about potential role redundancy raise the question of whether the HIRA requirement may be inadvertently increasing burden for potential recipients. Future work that captures the experiences of potential recipients is warranted.
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Affiliation(s)
- Juli Bollinger
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD
| | - Ann Eno
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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19
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Werbel WA, Durand CM. Solid Organ Transplantation in HIV-Infected Recipients: History, Progress, and Frontiers. Curr HIV/AIDS Rep 2019; 16:191-203. [PMID: 31093920 PMCID: PMC6579039 DOI: 10.1007/s11904-019-00440-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW End-stage organ disease prevalence is increasing among HIV-infected (HIV+) individuals. Trial and registry data confirm that solid organ transplantation (SOT) is efficacious in this population. Optimizing access to transplant and decreasing complications represent active frontiers. RECENT FINDINGS HIV+ recipients historically experienced 2-4-fold higher rejection. Integrase strand transferase inhibitors (INSTIs) minimize drug interactions and may reduce rejection along with lymphodepleting induction immunosuppression. Hepatitis C virus (HCV) coinfection has been associated with inferior outcomes, yet direct-acting antivirals (DAAs) may mitigate this. Experience in South Africa and the US HIV Organ Policy Equity (HOPE) Act support HIV+ donor to HIV+ recipient (HIV D+/R+) transplantation. SOT is the optimal treatment for end-stage organ disease in HIV+ individuals. Recent advances include use of INSTIs and DAAs in transplant recipients; however, strategies to improve access to transplant are needed. HIV D+/R+ transplantation is under investigation and may improve access and provide insights for HIV cure and pathogenesis research.
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Affiliation(s)
- William A. Werbel
- Department of Medicine, Johns Hopkins University School
of Medicine, Baltimore, MD
| | - Christine M. Durand
- Department of Medicine, Johns Hopkins University School
of Medicine, Baltimore, MD
- Sidney Kimmel Cancer Center, Johns Hopkins University
School of Medicine, Baltimore, MD
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20
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Expanding deceased donor kidney transplantation: medical risk, infectious risk, hepatitis C virus, and HIV. Curr Opin Nephrol Hypertens 2019; 27:445-453. [PMID: 30169460 DOI: 10.1097/mnh.0000000000000456] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Due to the organ shortage, which prevents over 90 000 individuals in the United States from receiving life-saving transplants, the transplant community has begun to critically reevaluate whether organ sources that were previously considered too risky provide a survival benefit to waitlist candidates. RECENT FINDINGS Organs that many providers were previously unwilling to use for transplantation, including kidneys with a high Kidney Donor Profile Index or from increased risk donors who have risk factors for window period hepatitis C virus (HCV) and HIV infection, have been shown to provide a survival benefit to transplant waitlist candidates compared with remaining on dialysis. The development of direct-acting antivirals to cure HCV infection has enabled prospective trials on the transplantation of organs from HCV-infected donors into HCV-negative recipients, with promising preliminary results. Changes in legislation through the HIV Organ Policy Equity Act have legalized transplantations from HIV-positive deceased donors to HIV-positive recipients for the first time in the United States. SUMMARY Critical reexamination of deceased donor organs that were previously discarded has resulted in greater utilization of these organs, an increased number of deceased donor transplants, and the provision of life-saving treatment to more transplant waitlist candidates.
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21
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Wolfe CR, Ison MG. Donor-derived infections: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13547. [PMID: 30903670 DOI: 10.1111/ctr.13547] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/18/2019] [Indexed: 12/12/2022]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation will review the current state of the art of donor-derived infections. Specifically, the guideline will summarize standardized definitions and approaches to defining imputability, updated data on the epidemiology of donor-derived infections, and approaches to risk mitigation against transmission of infections. This update will additionally provide guidance on the use of HIV+ donors in HIV+ recipients, the use of HCV-viremic donors in non-viremic recipients, donors with endemic infections, and donors with bacteremia, meningitis, and encephalitis. Lastly, the guidance will summarize an approach to recipients with a suspected donor-derived infection.
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Affiliation(s)
- Cameron R Wolfe
- Division of Infectious Diseases, Duke University, Durham, North Carolina
| | - Michael G Ison
- Divisions of Infectious Diseases & Organ Transplantation, Northwestern University Feinberg School of Medicine, Northwestern University Comprehensive Transplant Center, Chicago, Illinois
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22
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Durand CM, Halpern SE, Bowring MG, Bismut GA, Kusemiju OT, Doby B, Fernandez RE, Kirby CS, Ostrander D, Stock PG, Mehta SG, Turgeon NA, Wojciechowski D, Huprikar S, Florman S, Ottmann S, Desai NM, Cameron A, Massie AB, Tobian AA, Redd AD, Segev DL. Organs from deceased donors with false-positive HIV screening tests: An unexpected benefit of the HOPE act. Am J Transplant 2018; 18:2579-2586. [PMID: 29947471 PMCID: PMC6160348 DOI: 10.1111/ajt.14993] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 06/15/2018] [Accepted: 06/18/2018] [Indexed: 01/25/2023]
Abstract
Organs from deceased donors with suspected false-positive HIV screening tests were generally discarded due to the chance that the test was truly positive. However, the HIV Organ Policy Equity (HOPE) Act now facilitates use of such organs for transplantation to HIV-infected (HIV+) individuals. In the HOPE in Action trial, donors without a known HIV infection who unexpectedly tested positive for anti-HIV antibody (Ab) or HIV nucleic acid test (NAT) were classified as suspected false-positive donors. Between March 2016 and March 2018, 10 suspected false-positive donors had organs recovered for transplant for 21 HIV + recipients (14 single-kidney, 1 double-kidney, 5 liver, 1 simultaneous liver-kidney). Median donor age was 24 years; cause of death was trauma (n = 5), stroke (n = 4), and anoxia (n = 1); three donors were labeled Public Health Service increased infectious risk. Median kidney donor profile index was 30.5 (IQR 22-58). Eight donors were HIV Ab+/NAT-; two were HIV Ab-/NAT+. All 10 suspected false-positive donors were confirmed to be HIV-noninfected. Given the false-positive rates of approved assays used to screen > 20 000 deceased donors annually, we estimate 50-100 HIV false-positive donors per year. Organ transplantation from suspected HIV false-positive donors is an unexpected benefit of the HOPE Act that provides another novel organ source.
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Affiliation(s)
- Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Samantha E. Halpern
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gilad A. Bismut
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Brianna Doby
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Charles S. Kirby
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Darin Ostrander
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peter G. Stock
- Department of Surgery, University of California, San Francisco, CA
| | - Shikha G. Mehta
- Department of Medicine, University of Alabama, Birmingham, AL
| | | | | | - Shirish Huprikar
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sander Florman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shane Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Niraj M. Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Aaron A.R. Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Andrew D. Redd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD,National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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23
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Donating Another Person's Kidney: Avoiding the Discard of Organs by Retransplantation. Transplantation 2018; 102:2096-2100. [PMID: 29847504 DOI: 10.1097/tp.0000000000002308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Procurement and retransplantation of a previously transplanted kidney reclaim a functioning organ that would otherwise have been discarded. METHODS Case series of 3 retransplantation cases within the course of 1 calendar year. RESULTS These cases illustrate how to overcome the immunological, logistical, and technical barriers that have thus far limited the potential of this approach. Within this series, we report kidney reuse weeks and years after the original transplantation, as well as the previously undescribed "living donation of a deceased donor kidney". CONCLUSIONS Retransplantation of previously transplanted kidneys can be performed successfully and should be considered in the face of the current organ shortage.
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24
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Aguilar C, Husain S, Lortholary O. Recent advances in understanding and managing infectious diseases in solid organ transplant recipients. F1000Res 2018; 7:F1000 Faculty Rev-661. [PMID: 29899970 PMCID: PMC5968357 DOI: 10.12688/f1000research.14262.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2018] [Indexed: 12/30/2022] Open
Abstract
Background: Undergoing solid organ transplantation (SOT) exposes the recipient to various infectious risks, including possible transmission of pathogen by the transplanted organ, post-surgical infections, reactivation of latent pathogens, or novel infections. Recent advances: In the last few years, the emergence of Zika virus has raised concerns in the transplant community. Few cases have been described in SOT patients, and these were associated mainly with moderate disease and favorable outcome; the notable exception is a recent case of fatal meningo-encephalopathy in a heart transplant recipient. Because of the advances in treating hepatitis C, several teams recently started to use organs from hepatitis C-positive donors. The worldwide increasing incidence of multidrug-resistant pathogens, as well as the increasing incidence of Clostridioidesdifficile infection, is of particular concern in SOT patients. In the field of mycology, the main recent therapeutic advance is the availability of isavuconazole for the treatment of invasive aspergillosis and mucormycosis. This drug has the advantage of minimal interaction with calcineurin inhibitors. Regarding the viral reactivations occurring after transplant, cytomegalovirus (CMV) infection is still a significant issue in SOT patients. The management of resistant CMV remains particularly difficult. The approval of letermovir, albeit in bone marrow transplantation, and the therapeutic trial of maribavir bring a ray of hope. Another advancement in management of post-transplant infections is the development of in vitro tests evaluating pathogen-specific immune response, such as immunodiagnostics for CMV and, more recently, tests for monitoring immunity against BK virus. Conclusion: The increasing number of organ transplantations, the use of newer immunosuppressive drugs, and high-risk donors continue to define the landscape of transplant infectious diseases in the current era.
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Affiliation(s)
- Claire Aguilar
- Division of Infectious Diseases, Multi-Organ Transplant Program, Department of Medicine, University of Toronto, University Health Network, Toronto, ON, Canada
| | - Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Program, Department of Medicine, University of Toronto, University Health Network, Toronto, ON, Canada
| | - Olivier Lortholary
- Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Paris Descartes University, IHU Imagine, Paris, France
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25
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Van Pilsum Rasmussen SE, Henderson ML, Bollinger J, Seaman S, Brown D, Durand CM, Segev DL, Sugarman J. Perceptions, motivations, and concerns about living organ donation among people living with HIV. AIDS Care 2018; 30:1595-1599. [PMID: 29724118 DOI: 10.1080/09540121.2018.1469724] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Recent changes to United States law now permit people living with HIV (PLWH) to donate organs to HIV-infected (HIV+) recipients under research protocols. PLWH may have unique motivations for and concerns about living donation and understanding them is critical to ensuring the integrity of this novel approach to organ transplantation. We conducted in-depth interviews with PLWH from an urban HIV clinic who had previously indicated their willingness to be a living donor. Interviews elicited information on their motivations, perceived benefits, and concerns regarding living donation. Codes were identified inductively and then organized into themes and subthemes. Two coders independently analyzed the interviews and reconciled differences in coding by consensus. Thematic saturation was reached after 20 interviews. Motivations for living donation among PLWH included an altruistic desire to help others as well as HIV-specific motivations including solidarity with potential recipients and a desire to overcome HIV-related stigma. Perceived benefits of living donation included gratification from saving or improving the recipient's life and conferring a sense of normalcy for the HIV+ donor. Concerns about donation included the possibility of a prolonged recovery period, organ failure, and transmission of another strain of the virus to the recipients. PLWH had unique motivations, perceived benefits, and concerns about living donation in addition to those previously identified in the general population. These unique factors should be addressed in research protocols, informed consent processes, and the education and training of independent living donor advocates so that these endeavors are ethically sound.
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Affiliation(s)
| | - Macey L Henderson
- a Department of Surgery , Johns Hopkins University , Baltimore , USA.,b School of Nursing , Johns Hopkins University , Baltimore , USA
| | - Juli Bollinger
- c Berman Institute of Bioethics , Johns Hopkins University , Baltimore , USA
| | - Shanti Seaman
- d Department of Medicine , Johns Hopkins School of Medicine , Baltimore , USA
| | - Diane Brown
- d Department of Medicine , Johns Hopkins School of Medicine , Baltimore , USA
| | - Christine M Durand
- d Department of Medicine , Johns Hopkins School of Medicine , Baltimore , USA
| | - Dorry L Segev
- a Department of Surgery , Johns Hopkins University , Baltimore , USA.,b School of Nursing , Johns Hopkins University , Baltimore , USA.,e Department of Epidemiology , Johns Hopkins University Bloomberg School of Public Health , Baltimore , USA
| | - Jeremy Sugarman
- c Berman Institute of Bioethics , Johns Hopkins University , Baltimore , USA.,d Department of Medicine , Johns Hopkins School of Medicine , Baltimore , USA
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