1
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Marks CR, Durand CM, Bowring MG, Hand J, Abidi MZ, Malinis M, Barnaba B, Patel H, Pavlakis M, Alonso CD. Influence of induction therapy and antiretroviral regimen on outcomes in kidney transplant recipients living with human immunodeficiency. Transpl Infect Dis 2024; 26:e14287. [PMID: 38698669 DOI: 10.1111/tid.14287] [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: 12/19/2023] [Revised: 03/19/2024] [Accepted: 04/04/2024] [Indexed: 05/05/2024]
Abstract
PURPOSE Kidney transplantation has a survival benefit for people with human immunodeficiency virus (HIV) and end-stage kidney disease, however increased rates of rejection remain an issue. Questions remain regarding the impact of induction immunosuppression therapy and antiretroviral (ARV) choice on long-term outcomes. METHODS We performed a multicenter retrospective analysis of outcomes in recipients with HIV who received kidneys from donors without HIV transplanted between 2004 and 2019. The association between induction and ARV regimens and long-term outcomes including rejection, graft, and recipient survival over 5 years was investigated using Cox regression modeling. RESULTS Seventy-eight kidney transplants (KT) performed in 77 recipients at five US transplant centers were included, with median follow up of 7.1 (4.3-10.7) years. Overall recipient and graft survival were 83% and 67%, respectively. Rejection occurred in 37% (29/78). Recipients with rejection were more likely to be younger, recipients of deceased donor organs, and Black. Receipt of rabbit anti-thymocyte globulin (rATG) induction without protease-inhibitor (PI)-based ARVs was associated with 83% lower risk of rejection (adjusted hazard ratio (aHR) 0.17 (95% CI 0.05-0.63), p =.007) and a non-statistically significantly lower risk of graft failure (aHR 0.18 (0.03-1.16), p =.07) when compared to those who received other induction and ARV combinations. CONCLUSIONS In this multicenter retrospective study, we found a trend toward lower rejection and improved graft survival among those who received both rATG for induction and PI-sparing ARVs.
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Affiliation(s)
- Christin Rogers Marks
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | | | - Jonathan Hand
- Ochsner Health, New Orleans, Louisiana, USA
- Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, USA
| | - Maheen Z Abidi
- Division of Infectious Disease, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | | | | | - Het Patel
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Martha Pavlakis
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Carolyn D Alonso
- Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Su C, Ma Y, Liang H, Huang A, Deng W, Zhou J, Liu H. ART and Serum albumin are influencing factors of the 5-year survival rate of people living with HIV undergoing maintenance hemodialysis caused by HIV: A cohort study. Medicine (Baltimore) 2023; 102:e35494. [PMID: 37800798 PMCID: PMC10553035 DOI: 10.1097/md.0000000000035494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/13/2023] [Indexed: 10/07/2023] Open
Abstract
Human immunodeficiency virus (HIV) infection is one of the most prominent public health problems worldwide. The 5-year survival rate of people living with HIV undergoing maintenance hemodialysis (MHD) and the factors related to the survival rate have not been widely studied. This study calculated the 5-year survival rate of people living with HIV who were undergoing MHD and determined the risk factors that may affect the 5-year survival rate. All enrolled participants were followed up for more than 5 years from the first round of MHD. The survival rate of them was calculated, the Cox proportional hazards model was used for multivariate analysis, the Kaplan-Meier method was used to draw the survival curve, and the log-rank test was used to compare the survival time of different groups. A total of 121 participants were included in the study. Statistical analysis showed that the overall 5-year survival rate was 19.0%. The 6-, 12-, 24-, and 36-month survival rates were 71.90%, 56.20%, 41.32%, and 30.58%, respectively. Infection was the leading cause of death, accounting for 55.37%. The Cox proportional hazards model revealed that antiretroviral therapy (ART) and the serum albumin level after dialysis were independent protective factors for patient survival. The log-rank test showed that there was a significant difference in survival time between the ART and non-ART groups.
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Affiliation(s)
- Chunxiong Su
- Department of Blood Purification, the Fourth People’s Hospital of Nanning, Guangxi (Guangxi AIDS Clinical Treatment Center), Nanning, China
| | - Yuting Ma
- Department of Traditional Chinese Medicine, the Fourth People’s Hospital of Nanning, Guangxi (Guangxi AIDS Clinical Treatment Center), Nanning, China
| | - Huiping Liang
- Department of Medicine, GuangXi Medical College, Nanning, China
| | - Aixian Huang
- Department of Blood Purification, the Fourth People’s Hospital of Nanning, Guangxi (Guangxi AIDS Clinical Treatment Center), Nanning, China
| | - Wenhai Deng
- Department of Blood Purification, the Fourth People’s Hospital of Nanning, Guangxi (Guangxi AIDS Clinical Treatment Center), Nanning, China
| | - Jia Zhou
- Department of Blood Purification, the Fourth People’s Hospital of Nanning, Guangxi (Guangxi AIDS Clinical Treatment Center), Nanning, China
| | - Huaying Liu
- Department of Medicine, GuangXi Medical College, Nanning, China
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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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4
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Al Jurdi A, Liu EC, Salinas T, Aull MJ, Lubetzky M, Drelick AL, Small CB, Kapur S, Hartono C, Muthukumar T. Complications of rabbit anti-thymocyte globulin induction immunosuppression in HIV-infected kidney transplant recipients. FRONTIERS IN NEPHROLOGY 2022; 2:1047170. [PMID: 37675034 PMCID: PMC10479633 DOI: 10.3389/fneph.2022.1047170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/29/2022] [Indexed: 09/08/2023]
Abstract
Background Kidney transplantation in HIV-infected individuals with end-stage kidney disease is associated with improved survival compared to dialysis. Rabbit anti-thymocyte globulin (rATG) induction in HIV-infected kidney transplant recipients has been associated with a lower risk of acute rejection, but data on the rates of de novo malignancy and BK viremia in these patients is lacking. Methods We performed a single-center retrospective cohort study of adult HIV-infected individuals who underwent kidney transplantation with rATG induction between January 2006 and December 2016. The primary outcome was the development of de novo malignancy. Secondary outcomes included the development of BK viremia, infections requiring hospitalization, HIV progression, biopsy-proven acute rejection, and patient and allograft survival. Results Twenty-seven HIV-infected individuals with end-stage kidney disease received deceased (n=23) or living (n=4) donor kidney transplants. The cumulative rate of malignancy at five years was 29%, of whom 29% died because of advanced malignancy. BK viremia was detected in six participants (22%), of whom one had biopsy-proven BK virus-associated nephropathy and all of whom cleared the BK viremia. Five-year acute rejection rates, patient survival and death-censored allograft survival were 17%, 85% and 80% respectively. Conclusion rATG induction in HIV-infected kidney transplant recipients was associated with a low risk of acute rejection, but a potentially higher risk of de novo malignancies and BK viremia in this cohort. Screening strategies to closely monitor for BK virus infection and malignancy post-transplantation may improve outcomes in HIV-infected kidney transplant recipients receiving rATG induction.
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Affiliation(s)
- Ayman Al Jurdi
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, United States
| | - Esther C. Liu
- Department of Pharmacy, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
| | - Thalia Salinas
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
| | - Meredith J. Aull
- Division of Transplant Surgery, Department of Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Michelle Lubetzky
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
| | - Alexander L. Drelick
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Catherine B. Small
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
| | - Sandip Kapur
- Division of Transplant Surgery, Department of Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Choli Hartono
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
- The Rogosin Institute, New York, NY, United States
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- Department of Transplantation Medicine, NewYork Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
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5
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Lushniak SA, Durand CM. Donors with human immunodeficiency virus and hepatitis C virus for solid organ transplantation: what's new. Curr Opin Infect Dis 2022; 35:321-329. [PMID: 35849522 PMCID: PMC9718437 DOI: 10.1097/qco.0000000000000840] [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] [Indexed: 01/27/2023]
Abstract
PURPOSE OF THE REVIEW Passage of the HOPE Act and the advent of direct-acting antiviral (DAA) therapies have allowed for expansion of the donor organ pool to include donors with human immunodeficiency virus (HIV) and hepatitis C virus (HCV), thus providing new opportunities for waitlist candidates. This article provides updates on recent studies in solid organ transplantation (SOT) utilizing donors with HIV and HCV. RECENT FINDINGS The first pilot studies of kidney and liver transplantation from donors-with-HIV to recipients-with-HIV (HIV D+/R+) show robust patient survival, comparable graft survival to transplantation from donors without HIV (HIV D-/R+) and no increased rates of HIV breakthrough. The number of HIV D+ organs utilized has been lower than initial estimates due to several potential factors. With high numbers of overdose deaths from the opioid epidemic, there have been more HCV D+ organs available, leading to transplantation in recipients without HCV (HCV D+/R-) in combination with DAAs. Outcomes in both abdominal and thoracic HCV D+/R transplantation are excellent. SUMMARY With recent findings of good outcomes in both HIV D+/R+ and HCV D+/R- SOT, we feel the evidence supports both practices as standard clinical care options to mitigate organ shortage and reduce waitlist mortality.
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Affiliation(s)
| | - Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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6
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Durand CM, Zhang W, Brown DM, Yu S, Desai N, Redd AD, Bagnasco SM, Naqvi FF, Seaman S, Doby BL, Ostrander D, Bowring MG, Eby Y, Fernandez RE, Friedman-Moraco R, Turgeon N, Stock P, Chin-Hong P, Mehta S, Stosor V, Small CB, Gupta G, Mehta SA, Wolfe CR, Husson J, Gilbert A, Cooper M, Adebiyi O, Agarwal A, Muller E, Quinn TC, Odim J, Huprikar S, Florman S, Massie AB, Tobian AAR, Segev DL. A prospective multicenter pilot study of HIV-positive deceased donor to HIV-positive recipient kidney transplantation: HOPE in action. Am J Transplant 2021; 21:1754-1764. [PMID: 32701209 PMCID: PMC8073960 DOI: 10.1111/ajt.16205] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
HIV-positive donor to HIV-positive recipient (HIV D+/R+) transplantation is permitted in the United States under the HIV Organ Policy Equity Act. To explore safety and the risk attributable to an HIV+ donor, we performed a prospective multicenter pilot study comparing HIV D+/R+ vs HIV-negative donor to HIV+ recipient (HIV D-/R+) kidney transplantation (KT). From 3/2016 to 7/2019 at 14 centers, there were 75 HIV+ KTs: 25 D+ and 50 D- (22 recipients from D- with false positive HIV tests). Median follow-up was 1.7 years. There were no deaths nor differences in 1-year graft survival (91% D+ vs 92% D-, P = .9), 1-year mean estimated glomerular filtration rate (63 mL/min D+ vs 57 mL/min D-, P = .31), HIV breakthrough (4% D+ vs 6% D-, P > .99), infectious hospitalizations (28% vs 26%, P = .85), or opportunistic infections (16% vs 12%, P = .72). One-year rejection was higher for D+ recipients (50% vs 29%, HR: 1.83, 95% CI 0.84-3.95, P = .13) but did not reach statistical significance; rejection was lower with lymphocyte-depleting induction (21% vs 44%, HR: 0.33, 95% CI 0.21-0.87, P = .03). In this multicenter pilot study directly comparing HIV D+/R+ with HIV D-/R+ KT, overall transplant and HIV outcomes were excellent; a trend toward higher rejection with D+ raises concerns that merit further investigation.
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Affiliation(s)
- Christine M. Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wanying Zhang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Diane M. Brown
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sile Yu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Niraj Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew D. Redd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Serena M. Bagnasco
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Fizza F. Naqvi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shanti Seaman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brianna L. Doby
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Darin Ostrander
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Grace Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yolanda Eby
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Reinaldo E. Fernandez
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rachel Friedman-Moraco
- Department of Medicine, Emory University, Atlanta, Georgia
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Nicole Turgeon
- Department of Surgery, Emory University, Atlanta, Georgia
- Department of Surgery, Dell Medical School, University of Texas, Austin, Texas
| | - Peter Stock
- Department of Medicine, University of California, San Francisco, California
| | - Peter Chin-Hong
- Department of Medicine, University of California, San Francisco, California
| | - Shikha Mehta
- Section of Transplant Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Valentina Stosor
- Department of Infectious Diseases and Organ Transplantation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Catherine B. Small
- Department of Medicine/Division of Infectious Diseases, Weill Cornell Medicine, New York, New York
| | - Gaurav Gupta
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Sapna A. Mehta
- NYU Langone Transplant Institute, New York University Grossman School of Medicine, New York, New York
| | - Cameron R. Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Jennifer Husson
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Alexander Gilbert
- Medstar Georgetown Transplant Institute, Georgetown University School of Medicine, Washington, District of Columbia
| | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Georgetown University School of Medicine, Washington, District of Columbia
| | - Oluwafisayo Adebiyi
- Department of Medicine, Indiana University Health Hospital, Indianapolis, Indiana
| | - Avinash Agarwal
- Department of Surgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Elmi Muller
- Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Thomas C. Quinn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Jonah Odim
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Shirish Huprikar
- Recanati-Miller Transplantation Institute, The Mount Sinai Hospital, New York, New York
| | - Sander Florman
- Recanati-Miller Transplantation Institute, The Mount Sinai Hospital, New York, New York
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aaron A. R. Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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7
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Hughes K, Chang J, Stadtler H, Wyatt C, Klotman M, Blasi M. HIV-1 infection of the kidney: mechanisms and implications. AIDS 2021; 35:359-367. [PMID: 33229896 PMCID: PMC7855797 DOI: 10.1097/qad.0000000000002753] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
People living with HIV are at higher risk for acute and chronic kidney disease compared with uninfected individuals. Kidney disease in this population is multifactorial, with several contributors including HIV infection of kidney cells, chronic inflammation, genetic predisposition, aging, comorbidities, and coinfections. In this review, we provide a summary of recent advancements in the understanding of the mechanisms and implications of HIV infection and kidney disease, with particular focus on the role of direct HIV infection of renal cells.
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Affiliation(s)
- Kelly Hughes
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | - Jerry Chang
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | - Hannah Stadtler
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | - Christina Wyatt
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, NC, USA
| | - Mary Klotman
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | - Maria Blasi
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, NC, USA
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8
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Nambiar PH, Doby B, Tobian AAR, Segev DL, Durand CM. Increasing the Donor Pool: Organ Transplantation from Donors with HIV to Recipients with HIV. Annu Rev Med 2021; 72:107-118. [PMID: 33502896 DOI: 10.1146/annurev-med-060419-122327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Implementation of the HIV Organ Policy Equity (HOPE) Act marks a new era in transplantation, allowing organ transplantation from HIV+ donors to HIV+ recipients (HIV D+/R+ transplantation). In this review, we discuss major milestones in HIV and transplantation which paved the way for this landmark policy change, including excellent outcomes in HIV D-/R+ recipient transplantation and success in the South African experience of HIV D+/R+ deceased donor kidney transplantation. Under the HOPE Act, from March 2016 to December 2018, there were 56 deceased donors, and 102 organs were transplanted (71 kidneys and 31 livers). In 2019, the first HIV D+/R+ living donor kidney transplants occurred. Reaching the full estimated potential of HIV+ donors will require overcoming challenges at the community, organ procurement organization, and transplant center levels. Multiple clinical trials are ongoing, which will provide clinical and scientific data to further extend the frontiers of knowledge in this field.
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Affiliation(s)
- Puja H Nambiar
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205, USA
| | - Brianna Doby
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA;
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA;
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9
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Boyarsky BJ, Strauss AT, Segev DL. Transplanting Organs from Donors with HIV or Hepatitis C: The Viral Frontier. World J Surg 2021; 45:3503-3510. [PMID: 33471156 DOI: 10.1007/s00268-020-05924-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2020] [Indexed: 12/21/2022]
Abstract
A wide gap between the increasing demand for organs and the limited supply leads to immeasurable loss of life each year. The organ shortage could be attenuated by donors with human immunodeficiency virus (HIV) or hepatitis C virus (HCV). The transplantation of organs from HIV+ deceased donors into HIV+ individuals (HIV D+ /R+) was initiated in South Africa in 2010; however, this practice was forbidden in the USA until the HIV Organ Policy Equity (HOPE) Act in 2013. HIV D+/R+ transplantation is now practiced in the USA as part of ongoing research studies, helping to reduce waiting times for all patients on the waitlist. The introduction of direct acting antivirals for HCV has revolutionized the utilization of donors with HCV for HCV-uninfected (HCV-) recipients. This is particularly relevant as the HCV donor pool has increased substantially in the context of the rise in deaths related to drug overdose from injection drug use. This article serves to review the current literature on using organs from donors with HIV or HCV.
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Affiliation(s)
- Brian J Boyarsky
- Department of Surgery, Epidemiology Research Group in Organ Transplantation, Johns Hopkins University School of Medicine, 2000 E Monument St, Baltimore, MD, 21205, USA
| | - Alexandra T Strauss
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Epidemiology Research Group in Organ Transplantation, Johns Hopkins University School of Medicine, 2000 E Monument St, Baltimore, MD, 21205, USA. .,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA.
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10
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Tariq A, Kim H, Abbas H, Lucas GM, Atta MG. Pharmacotherapeutic options for kidney disease in HIV positive patients. Expert Opin Pharmacother 2020; 22:69-82. [PMID: 32955946 DOI: 10.1080/14656566.2020.1817383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Since the developmentof combined antiretroviral therapy (cART), HIV-associated mortality and the incidence of HIV-associated end-stage kidney disease (ESKD) has decreased. However, in the United States, an increase in non-HIV-associated kidney diseases within the HIV-positive population is expected. AREAS COVERED In this review, the authors highlight the risk factors for kidney disease within an HIV-positive population and provide the current recommendations for risk stratification and for the monitoring of its progression to chronic kidney disease (CKD), as well as, treatment. The article is based on literature searches using PubMed, Medline and SCOPUS. EXPERT OPINION The authors recommend clinicians (1) be aware of early cART initiation to prevent and treat HIV-associated kidney diseases, (2) be aware of cART side effects and discriminate those that may become more nephrotoxic than others and require dose-adjustment in the setting of eGFR ≤ 30ml/min/1.73m2, (3) follow KDIGO guidelines regarding screening and monitoring for CKD with a multidisciplinary team of health professionals, (4) manage other co-infections and comorbidities, (5) consider changing cART if drug induced toxicity is established with apparent eGFR decline of ≥ 10ml/min/1.73m2 or rising creatinine (≥0.5mg/dl) during drug-drug interactions, and (6) strongly consider kidney transplant in appropriately selected individuals with end stage kidney failure.
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Affiliation(s)
- Anam Tariq
- Division of Nephrology, Johns Hopkins University , Baltimore, MD, US
| | - Hannah Kim
- Division of Pediatric Nephrology, Johns Hopkins University , Baltimore, MD, US
| | - Hashim Abbas
- Division of Nephrology, Johns Hopkins University , Baltimore, MD, US
| | - Gregory M Lucas
- Division of Infectious Disease, Johns Hopkins University , Baltimore, MD, US
| | - Mohamed G Atta
- Division of Nephrology, Johns Hopkins University , Baltimore, MD, US
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11
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Abstract
: With current antiretroviral therapy, the lifespan of newly diagnosed persons with HIV (PWH) approaches that of uninfected persons. However, metabolic abnormalities related to both the disease and the virus itself, along with comorbidities of aging, have resulted in end-organ disease and organ failure as a major cause of morbidity and mortality. Solid organ transplantation is a life-saving therapy for PWH who have organ failure, and the approval of the HIV Organ Policy Equity Act has opened and expanded opportunities for PWH to donate and receive organs. The current environment of organ transplantation for PWH will be reviewed and future directions of research and treatment will be discussed.
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12
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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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13
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Aliyannissa A, Kuswiyanto RB, Setiabudi D, Nataprawira HM, Alam A, Sekarwana N. Correlation between CD4 count and glomerular filtration rate or urine protein:creatinine ratio in human immunodeficiency virus-infected children. Kidney Res Clin Pract 2020; 39:40-46. [PMID: 32146732 PMCID: PMC7105624 DOI: 10.23876/j.krcp.19.093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/29/2020] [Accepted: 02/04/2020] [Indexed: 01/23/2023] Open
Abstract
Background Studies on kidney complications in human immunodeficiency virus (HIV)-infected children are lacking. CD4 T lymphocytes are an important immune functions regulator and used as a basis for initiating antiretroviral therapy (ART) and monitoring disease progression. This study aims to determine the correlation between CD4 and estimated glomerular filtration rate (eGFR) or urine protein:creatinine ratio (uPCR) as markers of kidney complications. Methods This cross sectional study was conducted on HIV-infected children aged 5 to 18 years who visited the Teratai HIV Clinic at Hasan Sadikin Hospital for monthly monitoring in June 2019. CD4 count, eGFR based on the Schwartz formula, and uPCR were obtained. Correlation analysis was performed with the Pearson test. Results Subjects were 42 HIV-infected children, consisting of 23 males (54.8%) and 19 females (45.2%). Most children (65.0%) were in an advanced clinical stage and had been diagnosed with HIV for an average of 8 ± 3 years. All subjects had received ART, and six received tenofovir. Compliance to medications were good, and most subjects (79.0%) had normal nutritional status and CD4 count. All subjects had eGFR > 90 mL/min/1.73 m2, of which 21 (50.0%) were above normal value. Proteinuria was found in 12 patients (28.6%), and it was not significantly associated with clinical stages of HIV infection. CD4 count was correlated positively with eGFR (r = 0.473, P = 0.001) and negatively with uPCR (r = -0.284, P = 0.034). Conclusion The degree of immunodeficiency appears to correlate with severity of renal injury. Screening at diagnosis and periodic monitoring of kidney functions are crucial in all childhood HIV patients.
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Affiliation(s)
- Almira Aliyannissa
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Rahmat Budi Kuswiyanto
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Djatnika Setiabudi
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Heda Melinda Nataprawira
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Anggraini Alam
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Nanan Sekarwana
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
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14
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Boyle SM, Fehr K, Deering C, Raza A, Harhay MN, Malat G, Ranganna K, Lee DH. Barriers to kidney transplant evaluation in HIV-positive patients with advanced kidney disease: A single-center study. Transpl Infect Dis 2020; 22:e13253. [PMID: 31994821 DOI: 10.1111/tid.13253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/09/2020] [Accepted: 01/12/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND HIV-positive kidney transplant (KT) recipients have similar outcomes to HIV-negative recipients. However, HIV-positive patients with advanced kidney disease might face additional barriers to initiating the KT evaluation process. We sought to characterize comorbidities, viral control and management, viral resistance, and KT evaluation appointment rates in a cohort of KT evaluation-eligible HIV-positive patients. METHODS We included patients seen between January 1, 2008, and December 31, 2015, at a primary care HIV clinic who met KT evaluation eligibility by an estimated glomerular filtration rate ≤20 mL/min/1.73 meters2 or dialysis dependence. The primary outcome was a documented appointment for KT evaluation. RESULTS Of 3735 patients evaluated at the HIV primary clinic during the study period, 42 (1.6%) were KT evaluation-eligible patients. The median age was 47 years, 77% were male, and 95%, black. Median CD4 count was 328 cells/mm3 (IQR 175-461). Among the 63% percent with antiretroviral therapy (ART) prescription, 40% had viral loads >200 copies. Among patients with HIV resistance profiles (50%, n = 21), 52% had resistance to at least one class of ART. A majority (60%, n = 25) were scheduled for KT evaluation appointment, but of those, only 8% (n = 2) had evidence of appointments before dialysis dependence. Those without appointments had more schizophrenia (29% vs 4%, P = .02), resistance (78% vs 33%, P = .04), ART prescription (76% vs 48%, P = .04), and more kidney disease of unknown etiology (53% vs 8%, P = .02). CONCLUSION Kidney transplant evaluation-eligible HIV-positive patients had a high rate of evaluation appointments, but a low rate of preemptive evaluation appointments. Schizophrenia and viral resistance disproportionally affected patients without evaluation appointments. These data precede the recommendation for universal ART for all HIV+ patients, regardless of CD4 count and viral load, and must be interpreted in the context of this limitation.
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Affiliation(s)
- Suzanne M Boyle
- Division Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Kallie Fehr
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Catylin Deering
- Division of Infectious Disease, Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Abbas Raza
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Meera N Harhay
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania.,Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania.,Tower Health System, Tower Health Transplant Institute, West Reading, Pennsylvania
| | - Gregory Malat
- Department of Medicine, Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karthik Ranganna
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania.,Tower Health System, Tower Health Transplant Institute, West Reading, Pennsylvania
| | - Dong Heun Lee
- Division of Infectious Disease and HIV Medicine, Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania
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15
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Camargo JF, Pallikkuth S, Moroz I, Natori Y, Alcaide ML, Rodriguez A, Guerra G, Burke GW, Pahwa S. Pretransplant Levels of C-Reactive Protein, Soluble TNF Receptor-1, and CD38+HLADR+ CD8 T Cells Predict Risk of Allograft Rejection in HIV+ Kidney Transplant Recipients. Kidney Int Rep 2019; 4:1705-1716. [PMID: 31844807 PMCID: PMC6895601 DOI: 10.1016/j.ekir.2019.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/12/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION HIV-positive (HIV+) kidney transplant recipients exhibit a 2- to 3-fold increased risk of allograft rejection. Dysregulated immune activation in HIV infection persists despite successful antiretroviral therapy and is associated with non-AIDS morbidity, including renal disease. We hypothesized that the pathological levels of inflammation and immune activation associated with chronic HIV infection could have clinical utility in the prediction of rejection in HIV+ kidney recipients. METHODS Prospective cohort study of 22 HIV-negative (HIV-; donor) to HIV+ (recipient) kidney transplant recipients who underwent biomarker assessment pretransplant and were subsequently followed for development of acute rejection. Plasma levels of markers of inflammation (soluble tumor necrosis factor receptor 1 [sTNF-R1] and C-reactive protein [CRP]) and microbial translocation (soluble CD14 and lipopolysaccharide) were measured by enzyme-linked immunosorbent assay or chromogenic endpoint assay. Levels of activated (CD38+HLADR+) CD4+ and CD8+ T cells, and T regulatory cells (CD4+CD25highFoxP3+) were measured by flow cytometry. RESULTS Among the biomarkers evaluated, only the pretransplant levels of sTNF-R1, CRP, and frequencies of CD38+HLADR+ CD8 T cells, were found to be at significantly higher levels among patients who experienced biopsy-proven acute rejection. Confirming our hypothesis, patients with high pretransplant levels of sTNF-R1 or activated CD8+ T cells had a significantly increased 200-day cumulative incidence of biopsy-proven acute rejection (0 vs. 38% for both; P = 0.01). Similarly, pretransplant CRP levels higher than 5 μg/ml were associated with increased risk of acute rejection within the first 6 months post-transplant (0 vs. 43%; P = 0.01). CONCLUSION Biomarker-based identification of HIV+ recipients at increased risk for rejection might facilitate individualized induction immunosuppression regimens in this vulnerable patient population.
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Affiliation(s)
- Jose F. Camargo
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Suresh Pallikkuth
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ilona Moroz
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Yoichiro Natori
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Maria L. Alcaide
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Allan Rodriguez
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | | | - Savita Pahwa
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, Florida, USA
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16
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Liyanage L, Muzaale AD, Henderson ML, Durand CM. Living kidney donation in individuals with hepatitis C and HIV infection: rationale and emerging evidence. CURRENT TRANSPLANTATION REPORTS 2019; 6:167-176. [PMID: 32855901 PMCID: PMC7449146 DOI: 10.1007/s40472-019-00242-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW HIV-infected (HIV+) and hepatitis C virus-infected (HCV+) individuals with end-stage renal disease (ESRD) have decreased access to kidney transplantation. With new opportunities provided by the HIV Organ Policy Equity (HOPE) Act and direct-acting antivirals (DAAs) for HCV, we explore the potential risks and benefits of living donor kidney transplantation from HIV+ or HCV+ donors, from the perspective of both donor health and recipient outcomes. RECENT FINDINGS The HOPE Act permits organ donation from both deceased and living HIV+ persons to HIV+ recipients; however, there is only clinical experience with HIV+ deceased donors to date. Empirical evidence demonstrates a low but acceptable risk of ESRD in potential HIV+ living donors without comorbidities who have well-controlled infection in the absence of donation. With the availability of potent DAAs for eradication of HCV infection, growing evidence shows good outcomes with HCV seropositive and/or viremic deceased kidney donors, providing rationale to consider HCV+ living donors. SUMMARY HIV+ and HCV+ living donor kidney transplantation may improve access to transplant for vulnerable ESRD populations. Careful evaluation and monitoring are warranted to mitigate potential risks to donors and recipients.
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Affiliation(s)
- Luckmini Liyanage
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Abimereki D. Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Macey L. Henderson
- Department of Surgery, 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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17
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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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18
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Menon S, Munshi R. Blood-borne viral infections in pediatric hemodialysis. Pediatr Nephrol 2019; 34:1019-1031. [PMID: 30032326 DOI: 10.1007/s00467-018-4019-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/21/2018] [Accepted: 07/02/2018] [Indexed: 01/15/2023]
Abstract
Hemodialysis patients are at increased risk for development of blood-borne viral infections. Human immunodeficiency virus (HIV), a once fatal infection, has become treatable, but continues to be associated with increased mortality. Hepatitis B and C viral infections can lead to acute and chronic hepatitis, cirrhosis, or hepatocellular carcinoma. Young children and immunocompromised patients are more likely to develop chronic disease leading to increased morbidity and mortality, as compared to the healthy population. The hemodialysis population is at increased risk of blood-borne viral infections as compared to the general population due to multiple factors. Here we review risk factors of blood-borne viral infections, strategies for prevention, and approach to therapy in the pediatric hemodialysis population.
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Affiliation(s)
- Shina Menon
- Division of Nephrology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Raj Munshi
- Division of Nephrology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA.
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19
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Moving from the HIV Organ Policy Equity Act to HIV Organ Policy Equity in action: changing practice and challenging stigma. Curr Opin Organ Transplant 2019; 23:271-278. [PMID: 29432254 DOI: 10.1097/mot.0000000000000510] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW The HIV Organ Policy Equity (HOPE) Act, signed in 2013, reversed the federal ban on HIV-to-HIV transplantation. In this review, we examine the progress in HOPE implementation, the current status of HIV-to-HIV transplantation, and remaining challenges. RECENT FINDINGS Pursuant to the HOPE Act, the Department of Health and Human Services revised federal regulations to allow HIV-to-HIV transplants under research protocols adherent to criteria published by the National Institutes of Health. The first HIV-to-HIV kidney and liver transplants were performed at Johns Hopkins in March of 2016. Legal and practical challenges remain. Further efforts are needed to educate potential HIV+ donors and to support Organ Procurement Organizations. As of November 2017, there are 22 transplant centers approved to perform HIV-to-HIV transplants in 10 United Network for Organ Sharing regions. To date, 16 Organ Procurement Organizations in 22 states have evaluated HIV+ donors. The National Institutes of Health-funded HOPE in Action: A Multicenter Clinical Trial of HIV-to-HIV Deceased Donor (HIVDD) Kidney Transplantation Kidney Trial will launch at 19 transplant centers in December of 2017. A HOPE in Action Multicenter HIVDD Liver Trial is in development. SUMMARY Significant progress toward full HOPE implementation has been made though barriers remain. Some challenges are unique to HIV-HIV transplantation, whereas others are amplifications of issues across the current transplant system. In addition to a public health benefit for all transplant candidates in the United States, partnership on the HOPE Act has the potential to address systemic challenges to national donation and transplantation.
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20
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Wojciechowski D, Gandhi RT, Rosales IA. Case 11-2019: A 49-Year-Old Man with HIV Infection and Chronic Kidney Disease. N Engl J Med 2019; 380:1464-1472. [PMID: 30970193 DOI: 10.1056/nejmcpc1900417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- David Wojciechowski
- From the Departments of Medicine (D.W., R.T.G.) and Pathology (I.A.R.), Massachusetts General Hospital, and the Departments of Medicine (D.W., R.T.G.) and Pathology (I.A.R.), Harvard Medical School - both in Boston
| | - Rajesh T Gandhi
- From the Departments of Medicine (D.W., R.T.G.) and Pathology (I.A.R.), Massachusetts General Hospital, and the Departments of Medicine (D.W., R.T.G.) and Pathology (I.A.R.), Harvard Medical School - both in Boston
| | - Ivy A Rosales
- From the Departments of Medicine (D.W., R.T.G.) and Pathology (I.A.R.), Massachusetts General Hospital, and the Departments of Medicine (D.W., R.T.G.) and Pathology (I.A.R.), Harvard Medical School - both in Boston
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21
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Camargo JF, Anjan S, Chin-Beckford N, Morris MI, Abbo LM, Simkins J, Ciancio G, Chen LJ, Burke GW, Figueiro J, Guerra G, Kupin WL, Mattiazzi A, Ortigosa-Goggins M, Ram Bhamidimarri K, Roth D. Clinical outcomes in HIV+/HCV+ coinfected kidney transplant recipients in the pre- and post-direct-acting antiviral therapy eras: 10-Year single center experience. Clin Transplant 2019; 33:e13532. [PMID: 30866102 DOI: 10.1111/ctr.13532] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 03/02/2019] [Accepted: 03/08/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Previous studies have demonstrated inferior patient and graft survival following kidney transplant (KT) in HIV+/HCV+ coinfected patients compared to HIV+/HCV- recipients. However, these studies were conducted prior to the availability of direct-acting antiviral (DAA) agents and data in the modern era are lacking. METHODS Single center retrospective study of HIV+/HCV+ coinfected KT recipients (2007-2017). Outcomes were assessed for the pre-DAA and post-DAA (ie, after December 2013) eras including 1-year patient survival, death-censored graft survival, and acute rejection; and serious infections (defined as infections requiring admission to the intensive care unit during initial transplant hospitalization or re-admission to the hospital after discharge) within the first 6 months post-transplant. RESULTS A total of 13 consecutive HIV+/HCV+ recipients were identified. Median time of post-transplant follow-up was 722 days. Seven patients were transplanted in the DAA era; five of them had anti-HCV Ab+ donors, with two donors being HCV NAT positive; all received DAA therapy, six of them post-transplant (median time from KT to DAA: 83 days; IQR, 54-300). All the patients in the pre-DAA era were on a protease inhibitor-containing ART regimen. One-year patient and death-censored graft survivals were 83% and 67%, respectively, for the patients transplanted in the pre-DAA era, and 100% for both outcomes in the subgroup of patients transplanted in the post-DAA era (P > 0.05). Compared to patients in the post-DAA era, those in the pre-DAA era had higher incidence of serious infections (0 vs 67%; P = 0.02). Acute rejection exclusively occurred in the pre-DAA group (n = 1; 17%). CONCLUSIONS Outcomes of HIV+/HCV+ KT recipients, including HIV-/HCV+ to HIV+/HCV+ transplants, in the DAA era were excellent in this small cohort. Larger studies are needed.
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Affiliation(s)
- Jose F Camargo
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine Miami, Florida
| | - Shweta Anjan
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine Miami, Florida
| | | | - Michele I Morris
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine Miami, Florida
| | - Lilian M Abbo
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine Miami, Florida
| | - Jacques Simkins
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine Miami, Florida
| | - Gaetano Ciancio
- Department of Surgery, University of Miami Miller School of Medicine, and Miami Transplant Institute, Miami, Florida
| | - Linda J Chen
- Department of Surgery, University of Miami Miller School of Medicine, and Miami Transplant Institute, Miami, Florida
| | - George W Burke
- Department of Surgery, University of Miami Miller School of Medicine, and Miami Transplant Institute, Miami, Florida
| | - Jose Figueiro
- Department of Surgery, University of Miami Miller School of Medicine, and Miami Transplant Institute, Miami, Florida
| | - Giselle Guerra
- Division of Nephrology, Department of Medicine, University of Miami Miller School of Medicine Miami, Florida
| | - Warren L Kupin
- Division of Nephrology, Department of Medicine, University of Miami Miller School of Medicine Miami, Florida
| | - Adela Mattiazzi
- Division of Nephrology, Department of Medicine, University of Miami Miller School of Medicine Miami, Florida
| | - Mariella Ortigosa-Goggins
- Division of Nephrology, Department of Medicine, University of Miami Miller School of Medicine Miami, Florida
| | - Kalyan Ram Bhamidimarri
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine Miami, Florida
| | - David Roth
- Division of Nephrology, Department of Medicine, University of Miami Miller School of Medicine Miami, Florida
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Abstract
Human immunodeficiency virus (HIV) has become a chronic disease with a near normal life span resulting in increased risk of organ failure. HIV organ transplantation is a proven and accepted intervention in appropriately selected cases. HIV-positive organ transplantation into HIV-positive recipients is in its nascent stages. Hepatitis C virus, high rates of organ rejection, and immune dysregulation are significant remaining barriers to overcome. This article provides an overview of the transplantation needs in the HIV population focusing on kidney and liver transplants.
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Affiliation(s)
- Alan J Taege
- Department of Infectious Disease, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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23
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Sawinski D. ESRD patients coinfected with human immunodeficiency virus and Hepatitis C: Outcomes and management challenges. Semin Dial 2018; 32:159-168. [PMID: 30475425 DOI: 10.1111/sdi.12765] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
HIV infection is a major public health problem worldwide. Due to shared modes of acquisition, many HIV+ patients are coinfected with Hepatitis C. HIV/HCV coinfected patients have an increased burden of chronic kidney disease and are more likely to progress to end-stage renal disease. Dialysis survival is diminished in the coinfected population, even in the contemporary era. Kidney transplantation offers a survival benefit over remaining on dialysis; however, posttransplant outcomes are inferior compared to patients with HIV infection alone. Direct acting antiviral agents may offer an opportunity to improve patient survival, but there are significant drug-drug interactions involving the direct acting antiviral agents, antiretroviral therapy, and immunosuppression that the clinician should be aware of.
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Affiliation(s)
- Deirdre Sawinski
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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24
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Van Pilsum Rasmussen SE, Bowring MG, Shaffer AA, Henderson ML, Massie A, Tobian AAR, Segev DL, Durand CM. Knowledge, attitudes, and planned practice of HIV-positive to HIV-positive transplantation in US transplant centers. Clin Transplant 2018; 32:e13365. [PMID: 30074638 DOI: 10.1111/ctr.13365] [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: 06/07/2018] [Revised: 07/23/2018] [Accepted: 07/29/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND HIV+ donor organs can now be transplanted into HIV+ recipients (HIV D+/R+) following the HIV Organ Policy Equity (HOPE) Act. Implementation of the HOPE Act requires transplant center awareness and support of HIV D+/R+ transplants. METHODS To assess center-level barriers to implementation, we surveyed 209 transplant centers on knowledge, attitudes, and planned HIV D+/R+ protocols. RESULTS Responding centers (n = 114; 56%) represented all UNOS regions. Fifty centers (93 organ programs) planned HIV D+/R+ protocols (kidney n = 48, liver n = 34, pancreas n = 8, heart n = 2, lung = 1), primarily in the eastern United States (28/50). Most (91.2%) were aware that HIV D+/R+ transplantation is legal; 21.4% were unaware of research restrictions. Respondents generally agreed with HOPE research criteria except the required experience with ≥5 HIV+ transplants by organ type. Centers planning HIV D+/R+ protocols had higher transplant volume, HIV+ recipient volume, increased infectious risk donor utilization, and local HIV prevalence (P < 0.01). Centers not planning HIV D+/R+ protocols were more likely to believe their HIV+ candidates would not accept HIV+ donor organs (P < 0.001). Most centers (83.2%) supported HIV+ living donation. CONCLUSIONS Although many programs plan HIV D+/R+ transplantation, center-level barriers remain including geographic clustering of kidney/liver programs and concerns about HIV+ candidate willingness to accept HIV+ donor organs.
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Affiliation(s)
| | - Mary Grace Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ashton A Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Macey L Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Allan Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Aaron A R Tobian
- Transfusion Medicine Division, Department of Pathology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Christine M Durand
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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25
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Steel JL, Gordon EJ, Dulovich M, Kingsley K, Tevar A, Ganesh S, Brindley E, Sood P, Humar A. Transplant advocacy in the era of the human immunodeficiency virus organ policy equity act. Clin Transplant 2018; 32:e13309. [PMID: 29952035 DOI: 10.1111/ctr.13309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2018] [Indexed: 11/28/2022]
Abstract
In 2013, the Human Immunodeficiency Virus Organ Policy Equity (HOPE) Act was passed to permit the conduct of research on the transplantation of organs from donors infected with human immunodeficiency virus (HIV) into recipients who are HIV-positive. The HOPE Act workshop had many objectives including the discussion of the ethical issues involved in HIV-positive to HIV-positive transplantation, the informed consent process, and the role of independent advocates in the context of HIV to HIV transplantation. As of 2018, 22 transplant hospitals are approved, or undergoing approval, to perform HIV-positive to HIV-positive transplant surgeries, and this number is expected to grow. This study aims to: (i) briefly review the history and research of HIV+ transplantation prior to the HOPE Act, (ii) describe the ethical principles supporting the HOPE Act, (iii) characterize the informed consent process, and (iv) provide guidance regarding the role of independent advocates in the context of HIV-positive to HIV-positive transplantation.
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Affiliation(s)
- Jennifer L Steel
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Elisa J Gordon
- Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Michelle Dulovich
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kendal Kingsley
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amit Tevar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Swaytha Ganesh
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Emily Brindley
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Puneet Sood
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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26
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Shaffer AA, Durand CM. Solid Organ Transplantation for HIV-Infected Individuals. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018; 10:107-120. [PMID: 29977166 DOI: 10.1007/s40506-018-0144-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review The prevalence of end-stage organ disease is increasing among HIV-infected (HIV+) individuals. Individuals with well-controlled HIV on antiretroviral therapy (ART), without active opportunistic infections or cancer, and with specified minimum CD4 cell counts are appropriate transplant candidates. Infectious disease clinicians can improve access to transplantation for these patients and optimize management pre- and post-transplant. Recent Findings Clinical trials and registry-based studies demonstrate excellent outcomes for select HIV+ kidney and liver transplant recipients with similar patient and graft survival as HIV-uninfected patients. Elevated allograft rejection rates have been observed in HIV+ individuals; this may be related to a dysregulated immune system or drug interactions. Lymphocyte-depleting immunosuppression has been associated with lower rejection rates without increased infections using national registry data. Hepatitis C virus (HCV) coinfection has been associated with worse outcomes, however improvements are expected with direct-acting antivirals. Summary Solid organ transplantation should be considered for HIV+ individuals with end-stage organ disease. Infectious disease clinicians can optimize ART to avoid pharmacoenhancers, which interact with immunosuppression. The timing of HCV treatment (pre- or post-transplant) should be discussed with the transplant team. Finally, organs from HIV+ donors can now be considered for HIV+ transplant candidates, within research protocols.
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Affiliation(s)
- Ashton A Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, 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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27
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Cash A, Luo X, Chow EKH, Bowring MG, Shaffer AA, Doby B, Wickliffe CE, Alexander C, McRann D, Tobian AAR, Segev DL, Durand CM. HIV+ deceased donor referrals: A national survey of organ procurement organizations. Clin Transplant 2018; 32. [PMID: 29222929 DOI: 10.1111/ctr.13171] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND HIV-infected (HIV+) donor organs can be transplanted into HIV+ recipients under the HIV Organ Policy Equity (HOPE) Act. Quantifying HIV+ donor referrals received by organ procurement organizations (OPOs) is critical for HOPE Act implementation. METHODS We surveyed the 58 USA OPOs regarding HIV+ referral records and newly discovered HIV+ donors. Using data from OPOs that provided exact records and CDC HIV prevalence data, we projected a national estimate of HIV+ referrals. RESULTS Fifty-five (95%) OPOs reported HIV+ referrals ranging from 0 to 276 and newly discovered HIV+ cases ranging from 0 to 10 annually. Six OPOs in areas of high HIV prevalence reported more than 100 HIV+ donor referrals. Twenty-seven (47%) OPOs provided exact HIV+ referral records and 28 (51%) OPOs provided exact records of discovered HIV+ cases, totaling 1450 HIV+ referrals and 39 discovered HIV+ donors in the prior year. These OPOs represented 67% and 59% of prevalent HIV cases in the USA; thus, we estimated 2164 HIV+ referrals and 66 discovered HIV+ cases nationally per year. CONCLUSIONS OPOs reported a high volume of HIV+ referrals annually, of which a subset will be medically eligible for donation. Particularly in areas of high HIV prevalence, OPOs require ongoing support to implement the HOPE Act.
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Affiliation(s)
- Ayla Cash
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Xun Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eric K H Chow
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mary Grace Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashton A Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brianna Doby
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Corey E Wickliffe
- Department of Surgery, 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
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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28
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Race but not Hepatitis C co-infection affects survival of HIV + individuals on dialysis in contemporary practice. Kidney Int 2017; 93:706-715. [PMID: 29107361 DOI: 10.1016/j.kint.2017.08.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 08/08/2017] [Accepted: 08/17/2017] [Indexed: 12/29/2022]
Abstract
Individuals with HIV infection are at elevated risk of developing end-stage renal disease. However, their outcomes after starting chronic dialysis in the contemporary era of widespread antiretroviral therapy are not well described. Using detailed data from a national dialysis provider, we determined HIV status by administrative codes and antiretroviral medication prescriptions, with hepatitis C virus (HCV) co-infection status provided by routinely measured serology. The survival on dialysis among 5348 individuals in the HIV+ group and 1863 HIV+/HCV+ individuals to a HIV-/HCV- reference cohort was compared. Race significantly modified the effect of HIV and HIV/HCV infection on mortality. In a multivariable model, HIV infection was not associated with an increased risk of death among Caucasians (hazard ratio 1.03, 95% confidence interval 0.91-1.16) but HIV/HCV co-infection (1.48, 1.18-1.87) was. In the same model for non-Caucasians, both HIV infection (1.44, 1.37-1.52) and HIV/HCV co-infection (1.71, 1.60-1.84) were significantly associated with higher mortality. A secondary analysis using propensity scores yielded similar results. Median follow-up for the reference group was 645 days (interquartile range 230-1323), 772 days (276-1623) for the HIV+ group and 777 days (334-1665) for the co-infected group. Thus, in the contemporary era of widespread antiretroviral use, HIV infection remains associated with a significant reduction in dialysis survival for non-Caucasians while HIV/HCV co-infection is associated with impaired survival regardless of race or ethnicity. Hence, interventions to improve the care for these vulnerable populations are needed.
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29
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Lee DH, Boyle SM, Malat GE, Kern C, Milrod C, DeBellis S, Harhay MN, Ranganna K, Guy S, Talluri S, Bias T, Doyle A. Barriers to listing for HIV-infected patients being evaluated for kidney transplantation. Transpl Infect Dis 2017; 19. [PMID: 28921783 DOI: 10.1111/tid.12777] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 06/04/2017] [Accepted: 06/14/2017] [Indexed: 12/14/2022]
Abstract
Human immunodeficiency virus (HIV)-infected patients have excellent outcomes following kidney transplantation (KT) but still might face barriers in the evaluation and listing process. The aim of this study was to characterize the patient population, referral patterns, and outcomes of HIV-infected patients who present for KT evaluation. We performed a single-center retrospective cohort study of HIV-infected patients who were evaluated for KT. The primary outcome was time to determination of eligibility for KT. Between 2011 and 2015, 105 HIV-infected patients were evaluated for KT. Of the 105 patients, 73 were listed for transplantation by the end of the study period. For those who were deemed ineligible, the most common reasons cited were active substance abuse (n = 7, 22%) and failure to complete the full transplant evaluation (n = 7, 22%). Our cohort demonstrated a higher proportion of HIV-infected patients eligible for KT than in previous studies, likely secondary to advances in HIV management. Among those who were denied access to transplantation, we identified that many were unable to complete the evaluation process, and that active substance abuse was common. Future prospective studies should examine reasons and potential interventions for the lack of follow-through and drug use we observed in this population.
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Affiliation(s)
- Dong Heun Lee
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Suzanne M Boyle
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Gregory E Malat
- Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Christopher Kern
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Charles Milrod
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Shannon DeBellis
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Meera N Harhay
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Karthik Ranganna
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Stephen Guy
- Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Sindhura Talluri
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Tiffany Bias
- Department of Medicine, Drexel University, Philadelphia, PA, USA
| | - Alden Doyle
- Department of Medicine, Drexel University, Philadelphia, PA, USA
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30
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Laranjinha I, João Matias P, Dickson J, Estibeiro H, Boquinhas H, Barata JD. Prognostic Factors of Human Immunodeficiency Virus-Infected Patients on Chronic Hemodialysis. Blood Purif 2017; 44:244-250. [PMID: 28968598 DOI: 10.1159/000478966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 06/25/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS The number of human immunodeficiency virus (HIV)-infected patients on hemodialysis (HD) have increased, and their prognostic factors are still poorly clarified. The study aimed to identify factors that can influence the survival of HIV-infected patients on HD. METHODS We performed a retrospective cohort study of 44 HIV-infected patients on HD. RESULTS A total of 17 patients (39%) died. Median survival on HD was 30.8 months and the survival rate at 1 and 5 years was 82.5 and 62.9%, respectively. Male (relative risk [RR] 3.1, p = 0.040) and blacks (RR 2.5, p = 0.037) had higher risk of death. The patients who died had a shorter duration of HIV infection (p = 0.028), had a higher viral load (p = 0.044), more opportunistic infections (p = 0.013), and a lower serum albumin (p = 0.009). Lower serum albumin, nonsexual HIV transmission, viral load, opportunistic infections, and usage of catheters were associated with lower survival. CONCLUSION Several demographic, viral, and dialysis variables may help to predict survival of this population. The intervention in these factors could improve their prognosis.
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Affiliation(s)
- Ivo Laranjinha
- Department of Nephrology, Hospital de Santa Cruz, Lisbon, Portugal
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31
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Boyle SM, Lee DH, Wyatt CM. HIV in the dialysis population: Current issues and future directions. Semin Dial 2017; 30:430-437. [PMID: 28608994 DOI: 10.1111/sdi.12615] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Antiretroviral therapy has significantly reduced mortality due to HIV infection, but the aging HIV-positive patient population now faces a growing burden of comorbidity. This review describes the changing epidemiology of chronic kidney disease and end-stage renal disease in this population, and highlights recent advances in antiretroviral therapy and kidney transplantation that directly impact the care of patients with HIV infection and end-stage renal disease.
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Affiliation(s)
- Suzanne M Boyle
- Division of Nephrology and Hypertension, Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Dong H Lee
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Christina M Wyatt
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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32
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Abstract
OBJECTIVE To determine the survival benefit of kidney transplantation in human immunodeficiency virus (HIV)-infected patients with end-stage renal disease (ESRD). SUMMARY BACKGROUND DATA Although kidney transplantation (KT) has emerged as a viable option for select HIV-infected patients, concerns have been raised that risks of KT in HIV-infected patients are higher than those in their HIV-negative counterparts. Despite these increased risks, KT may provide survival benefit for the HIV-infected patient with ESRD, yet this important clinical question remains unanswered. METHODS Data from the Scientific Registry of Transplant Recipients were linked to IMS pharmacy fills (January 1, 2001 to October 1, 2012) to identify and study 1431 HIV-infected KT candidates from the first point of active status on the waiting list. Time-dependent Cox regression was used to establish a counterfactual framework for estimating survival benefit of KT. RESULTS Adjusted relative risk (aRR) of mortality at 5 years was 79% lower after KT compared with dialysis (aRR 0.21; 95% CI 0.10-0.42; P <0.001), and statistically significant survival benefit was achieved by 194 days of KT. Among patients coinfected with hepatitis C, aRR of mortality at 5 years was 91% lower after KT compared with dialysis (aRR 0.09; 95% CI 0.02-0.46; P < 0.004); however, statistically significant survival benefit was not achieved until 392 days after KT. CONCLUSIONS Evidence suggests that for HIV-infected ESRD patients, KT is associated with a significant survival benefit compared with remaining on dialysis.
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33
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CD4 Count in HIV- Brain-Dead Donors: Insight into Donor Risk Assessment for HIV+ Donors. Transplantation 2017; 101:831-835. [PMID: 27748702 DOI: 10.1097/tp.0000000000001506] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The Human Immunodeficiency Virus (HIV) Organ Policy Equity Act allows for transplantation of organs from HIV-infected individuals (HIV+), provided it is performed under a research protocol. The safety assessment of an organ for transplantation is an essential element of the donation process. The risk for HIV-associated opportunistic infections increases as circulating CD4+ lymphocytes decrease to less than 200 cells/μL; however, the numbers of circulating CD4+ cells in the HIV-negative (HIV-) brain-dead donor (BDD) is not known. METHODS Circulating T-lymphocyte subset profiles in conventional HIV- BDD were measured in 20 BDD in a clinical laboratory. RESULTS The mean age of the BDD cohort was 48.7 years, 95% were white and 45% were women. The average body mass index was 29.2 kg/m. Cerebrovascular accident (40%) was the most prevalent cause of death. Sixteen (80%) subjects had a CD4 count ≤441 cells/μL (lower limit of normal) and 11 (55%) had a CD4 count less than 200 cells/μL; 11 (55%) subjects had a CD8 count ≤125 cells/μL (lower limit of normal). CD4/CD8 ratio was below normal in 3 patients (normal, 1.4-2.6). No recipient had a recognized donor-associated adverse event. CONCLUSIONS Absolute numbers of CD4 and CD8 T-lymphocytes are commonly reduced after brain death in HIV- individuals. Thus, CD4 absolute numbers are an inconsistent metric for assessing organ donor risk, irrespective of HIV status.
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An Exception to the Rule or a Rule for the Exception? The Potential of Using HIV-Positive Donors in Canada. Transplantation 2017; 101:671-674. [PMID: 28323771 DOI: 10.1097/tp.0000000000001630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Selected human immunodeficiency virus (HIV)-infected patients with end organ failure can safely receive an organ transplant from an HIV uninfected donor. Recent demonstration of the short term safety of organ transplantation between HIV-infected persons prompted a change in US American law to allow such transplantations. Prompted by the recent completion of the first organ transplantation between HIV-infected persons in Canada, we review Canadian law regarding the use of organs from HIV-infected donors, estimate the number of potential HIV-infected donors in Canada, and critically review considerations related to advancing organ transplantation from HIV-infected donors in Canada. Existing legislation allows organ transplantation from an HIV-infected donor under exceptional medical circumstances and therefore no change in legislation is required to increase utilization of organs from HIV-infected donors for transplantation in Canada. Among 335,793 hospital deaths between 2005 and 2009 in Canadian provinces excluding Quebec, 39 potential HIV-infected donors were identified. The actual number of HIV potential donors is estimated to be approximately 60% lower (3-5 potential donor per year), if the absence of viremia is required for transplantation. Although offering all Canadians the opportunity to donate organs is a laudable goal, further research to understand the need for HIV-positive donors and the willingness of HIV-positive recipients to accept organs from HIV-positive donors is needed to inform future policy regarding organ donation from HIV-infected persons in Canada.
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35
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Chandran S, Stock PG. Opportunities and Challenges for Kidney Donation from and to HIV-Positive Individuals. Clin J Am Soc Nephrol 2017; 12:385-387. [PMID: 28232405 PMCID: PMC5338696 DOI: 10.2215/cjn.00740117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
| | - Peter G. Stock
- Surgery, University of California, San Francisco, California
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36
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Locke JE, Mehta S, Sawinski D, Gustafson S, Shelton BA, Reed RD, MacLennan P, Bolch C, Durand C, Massie A, Mannon RB, Gaston R, Saag M, Overton T, Segev DL. Access to Kidney Transplantation among HIV-Infected Waitlist Candidates. Clin J Am Soc Nephrol 2017; 12:467-475. [PMID: 28232406 PMCID: PMC5338712 DOI: 10.2215/cjn.07460716] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 12/02/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Kidney transplantation among HIV-infected patients with ESRD confers a significant survival benefit over remaining on dialysis. Given the high mortality burden associated with dialysis, understanding access to kidney transplantation after waitlisting among HIV+ candidates is warranted. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data from the Scientific Registry of Transplant Recipients were linked to Intercontinental Marketing Statistics pharmacy fills (January 1, 2001 to October 1, 2012) so that we could identify and study 1636 HIV+ (defined as having filled one or more antiretroviral medications unique to HIV treatment) and 72,297 HIV- kidney transplantation candidates. RESULTS HIV+ waiting list candidates were more often young (<50 years old: 62.7% versus 37.6%; P<0.001), were more often men (75.2% versus 59.3%; P<0.001), were more often black (73.6% versus 27.9%; P<0.001), had longer time on dialysis (years: 2.5 versus 0.8; P<0.001), were more often coinfected with hepatitis C virus (9.0% versus 3.9%; P<0.001), and were less likely to remain active on the waiting list (37.7% versus 49.4%; P<0.001). Waitlist mortality among HIV+ candidates was similar compared with HIV- candidates (adjusted hazard ratio, 1.03; 95% confidence interval, 0.89 to 1.20; P=0.67). In contrast, likelihood of living donor kidney transplantation was 47% lower (adjusted hazard ratio, 0.53; 95% confidence interval, 0.44 to 0.64; P<0.001), and there was a trend toward lower likelihood of deceased donor kidney transplantation (adjusted hazard ratio, 0.87; 95% confidence interval, 0.74 to 1.01; P=0.07) compared with in HIV- candidates. CONCLUSIONS Our findings highlight the need for additional study to better understand disparities in access to kidney transplantation, particularly living donor kidney transplantation, among HIV+ kidney waitlist candidates.
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Affiliation(s)
| | - Shikha Mehta
- Medicine, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, Alabama
| | - Deirdre Sawinski
- Department of Medicine, University of Pennsylvania Comprehensive Transplant Center, Philadelphia, Pennsylvania
| | - Sally Gustafson
- Department of Analytics, Scientific Registry of Transplant Recipients, Minneapolis, Minnesota; and Departments of
| | | | | | | | - Charlotte Bolch
- Department of Analytics, Scientific Registry of Transplant Recipients, Minneapolis, Minnesota; and Departments of
| | | | - Allan Massie
- Surgery, Johns Hopkins University Comprehensive Transplant Center, Baltimore, Maryland
| | - Roslyn B. Mannon
- Medicine, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, Alabama
| | - Robert Gaston
- Medicine, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, Alabama
| | - Michael Saag
- Medicine, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, Alabama
| | - Turner Overton
- Medicine, University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, Alabama
| | - Dorry L. Segev
- Surgery, Johns Hopkins University Comprehensive Transplant Center, Baltimore, Maryland
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37
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Ambaraghassi G, Cardinal H, Corsilli D, Fortin C, Fortin MC, Martel-Laferrière V, Malaise J, Pâquet MR, Rouleau D. First Canadian Case Report of Kidney Transplantation From an HIV-Positive Donor to an HIV-Positive Recipient. Can J Kidney Health Dis 2017; 4:2054358117695792. [PMID: 28321326 PMCID: PMC5347410 DOI: 10.1177/2054358117695792] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Kidney transplantation has become standard of care for carefully selected patients living with human immunodeficiency virus (HIV) and end-stage renal disease (ESRD) in the highly active antiretroviral therapy (HAART) era. American and European prospective cohort studies have reported similar patient and graft survival compared with HIV-negative kidney transplant recipients. Despite an increased rate of acute rejection, partially due to drug interactions, HIV immunovirologic parameter generally remains under control during immunosuppression. A few cases of kidney transplantation between HIV-infected patients were done in South Africa and showed favorable results. No cases of kidney transplantation from an HIV-positive donor in Canada have previously been reported. PRESENTING CONCERNS OF THE PATIENT A 60-year-old Canadian man with HIV infection presented in 2007 with symptoms compatible with acute renal failure secondary to IgA nephropathy. Chronic kidney disease resulted after the acute episode. DIAGNOSES Hemodialysis was started in 2012. The patient was referred for a kidney transplantation evaluation. INTERVENTIONS The patient underwent kidney transplantation from an HIV-positive donor in January 2016. The recipient's antiretroviral regimen consisted of abacavir, lamivudine, and dolutegravir. No drug interactions have been reported between these antiretrovirals and the maintenance immunosuppressive regimen used. OUTCOMES The outcome at 7 months post transplantation was excellent, with good graft function and adequate control of HIV replication, in the absence of opportunistic infections at a time when immunosuppression is at its highest intensity. No acute rejection was reported. An episode of bacteremic graft pyelonephritis due to Enterococcus faecalis was successfully treated after transplantation. NOVEL FINDING With careful selection of patient, kidney transplantation between HIV-infected patients is a viable option. The use of antiretroviral drugs free of interactions simplified the dosing and management of the immunosuppressive drugs.
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Affiliation(s)
- Georges Ambaraghassi
- Département de Microbiologie médicale et Infectiologie, Hôpital Maisonneuve-Rosemont, Québec, Canada
| | - Héloïse Cardinal
- Département de Néphrologie, Hôpital Notre-Dame, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| | - Daniel Corsilli
- Département des Soins intensifs, Hôpital Saint-Luc, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| | - Claude Fortin
- Département de Microbiologie médicale et Infectiologie, Hôpital Notre-Dame, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| | - Marie-Chantal Fortin
- Département de Néphrologie, Hôpital Notre-Dame, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| | - Valérie Martel-Laferrière
- Département de Microbiologie médicale et Infectiologie, Hôpital Saint-Luc, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| | - Jacques Malaise
- Département de Chirurgie, Hôpital Notre-Dame, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| | - Michel R Pâquet
- Département de Néphrologie, Hôpital Notre-Dame, Centre Hospitalier de l'Université de Montréal, Québec, Canada
| | - Danielle Rouleau
- Département de Microbiologie médicale et Infectiologie, Hôpital Notre-Dame, Centre Hospitalier de l'Université de Montréal, Québec, Canada
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Lee YC, Hung CC, Cheng A, Liu WC, Wu PY, Yang SP, Zhang JY, Luo YZ, Chang HY, Sun HY, Chang SC. Willingness of human immunodeficiency virus-positive patients to donate their organs for transplantation in Taiwan: a cross-sectional questionnaire survey. Transpl Infect Dis 2016; 18:856-861. [PMID: 27663143 DOI: 10.1111/tid.12614] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/16/2016] [Accepted: 07/14/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND With the introduction of combination antiretroviral therapy (cART) that has significantly improved survival, human immunodeficiency virus (HIV)-positive patients may be potential organ donors to HIV-positive recipients in a few countries. Organ shortage remains a challenge for organ transplantation in Taiwan, where organ donation by HIV-positive patients remains prohibited by law. METHODS We assessed the willingness of organ donation (should they be pronounced brain dead, and the ban on HIV-positive organ donation be lifted) among HIV-positive patients who received regular HIV care at a university hospital in a cross-sectional survey between May and August 2015 with the use of an anonymous, self-administered questionnaire interview. RESULTS Of the 1010 participants, 93.7% were receiving cART with the latest mean CD4 count and plasma HIV RNA load of 587 cells/mm3 and 2.73 log10 copies/mL, respectively. Overall, 71.9% were willing to donate organs. In multivariate analysis, factors associated with willingness to donate organs included college or graduate school diploma (odds ratio [OR] 1.571, 95% confidence interval [CI] 1.166-2.191), registered willingness to donate in the National Health Insurance system (OR 9.430, 95% CI 1.269-70.051), and knowledge of the information on HIV-positive deceased donors (HIVDD) (OR 1.673, 95% CI 1.073-2.608). CONCLUSIONS We concluded that a significant proportion (71.9%) of HIV-positive Taiwanese patients were willing to donate their organs. The willingness was associated with a higher education level, prior registered willingness to donate organs, and awareness of HIVDD.
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Affiliation(s)
- Yi-Chieh Lee
- Department of Internal Medicine, Lotung Poh-Ai Hospital, Medical Lo-Hsu Foundation, I-Lan, Taiwan
| | - Chien-Ching Hung
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Aristine Cheng
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Wen-Chun Liu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Pei-Ying Wu
- Center of Infection Control, National Taiwan University Hospital, Taipei, Taiwan
| | - Shang-Ping Yang
- Center of Infection Control, National Taiwan University Hospital, Taipei, Taiwan
| | - Jun-Yu Zhang
- Center of Infection Control, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Zhen Luo
- Center of Infection Control, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsi-Yen Chang
- Center of Infection Control, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Durand CM, Segev D, Sugarman J. Realizing HOPE: The Ethics of Organ Transplantation From HIV-Positive Donors. Ann Intern Med 2016; 165:138-42. [PMID: 27043422 PMCID: PMC4949150 DOI: 10.7326/m16-0560] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The HIV Organ Policy Equity (HOPE) Act now allows transplantation of organs from HIV-positive living and deceased donors to HIV-positive individuals with end-stage organ disease in the United States. Although clinical experience with such transplants is limited to a small number of deceased-donor kidney transplants from HIV-positive to HIV-positive persons in South Africa, unprecedented HIV-positive-to-HIV-positive liver transplantations and living-donor kidney transplantations are also now on the horizon. Initially, all HIV-positive-to-HIV-positive transplantations will occur under research protocols with safeguards and criteria mandated by the National Institutes of Health. Nevertheless, this historic change brings ethical opportunities and challenges. For HIV-positive individuals needing an organ transplant, issues of access, risk, and consent must be considered. For potential HIV-positive donors, there are additional ethical challenges of privacy, fairness, and the right to donate. Careful consideration of the ethical issues involved is critical to the safe and appropriate evaluation of this novel approach to transplantation.
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Saracho R, Martín Escobar E, Comas Farnés J, Arcos E, Mazuecos Blanca A, Gentil Govantes MÁ, Castro de la Nuez P, Zurriaga Ó, Ferrer Alamar M, Bouzas Caamaño E, García Falcón T, Portolés Pérez J, Herrero Calvo JA, Chamorro Jambrina C, Moina Eguren Í, Rodrigo de Tomás MT, Abad Díez JM, Sánchez Miret JI, Alvarez Lipe R, Díaz Tejeiro R, Moreno Alía I, Torres Guinea M, Huarte Loza E, Artamendi Larrañaga M, Fernández Renedo C, González Fernández R, Sánchez Álvarez E, Alonso de la Torre R. Clinical evolution of chronic renal patients with HIV infection in replacement therapy. Nefrologia 2015; 35:457-64. [PMID: 26409500 DOI: 10.1016/j.nefro.2015.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 06/05/2015] [Accepted: 06/30/2015] [Indexed: 11/17/2022] Open
Abstract
Patients on renal replacement therapy (RRT) infected with the human immunodeficiency virus (HIV) are a special group with growing interest. In order to study the epidemiological data of HIV+ patients on RRT in Spain, we collected individual information from 2004-2011 (period of use of highly active antiretroviral therapy [HAART] in the Autonomous Communities of Andalusia, Aragon, Asturias, Catalonia, Valencia, Castilla la Mancha, Castilla León, Galicia, Madrid, La Rioja and the Basque Country, comprising 85% of the Spanish population. A total of 271 incident and 209 prevalent patients were analysed. They were compared with the remaining patients on RRT during the same period. The annual incidence was 0.8 patients per one million inhabitants, with a significant increase during the follow-up period. The proportion of prevalent HIV+ patients was 5.1 per 1,000 patients on RRT (95% confidence interval [CI] 4.4-5.8. Although glomerular diseases constituted the majority of cases (42%), diabetic nephropathy was the cause in 14% of patients. The nation-wide totals for these percentages were 13 and 25%, respectively. Compared to the total of patients in treatment, the risk of death was significantly higher in the HIV+ group: hazard ratio (HR) adjusted for age, sex and diabetes was 2.26 (95% CI 1.74 - 2.91). Hepatitis C coinfection increased the risk of death in the HIV+ group (HR 1.77; 95% CI 1.10 - 2.85). The probability of kidney transplantation in HIV+ was only 17% after 7 years, comparing with total RTT patients (HR 0.15; 95% CI: 0.10-0.24). Despite the use of HAART, the incidence of HIV+ patients on dialysis has increased; their mortality still exceeds non-HIV patients, and they have a very low rate of transplantation. It is necessary to further our knowledge of this disease in order to improve results.
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Affiliation(s)
- Ramón Saracho
- Coordinación de Registros, Sociedad Española de Nefrología.
| | | | - Jordi Comas Farnés
- Registre de Malalts Renals de Catalunya, Organització Catalana de Trasplantaments
| | - Emma Arcos
- Registre de Malalts Renals de Catalunya, Organització Catalana de Trasplantaments
| | | | | | | | - Óscar Zurriaga
- Registre de Malalts Renals de la Comunidad Valenciana (REMRENAL)
| | | | | | | | | | | | | | | | | | | | | | | | - Rafael Díaz Tejeiro
- Registro de Enfermos Renales en Tratamiento Sustitutivo de Castilla-La Mancha
| | | | - Marta Torres Guinea
- Registro de Enfermos Renales en Tratamiento Sustitutivo de Castilla-La Mancha
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Boyarsky BJ, Durand CM, Palella FJ, Segev DL. Challenges and Clinical Decision-Making in HIV-to-HIV Transplantation: Insights From the HIV Literature. Am J Transplant 2015; 15:2023-30. [PMID: 26080612 DOI: 10.1111/ajt.13344] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 03/23/2015] [Accepted: 04/04/2015] [Indexed: 01/25/2023]
Abstract
Life expectancy among HIV-infected (HIV+) individuals has improved dramatically with effective antiretroviral therapy. Consequently, chronic diseases such as end-stage liver and kidney disease are growing causes of morbidity and mortality. HIV+ individuals can have excellent outcomes after solid organ transplantation, and the need for transplantation in this population is increasing. However, there is a significant organ shortage, and HIV+ individuals experience higher mortality rates on transplant waitlists. In South Africa, the use of organs from HIV+ deceased donors (HIVDD) has been successful, but until recently federal law prohibited this practice in the United States. With the recognition that organs from HIVDD could fill a critical need, the HIV Organ Policy Equity (HOPE) Act was passed in November 2013, reversing the federal ban on the use of HIV+ donors for HIV+ recipients. In translating this policy into practice, the biologic risks of using HIV+ donors need to be carefully considered. In this mini-review, we explore relevant aspects of HIV virology, antiretroviral treatment, drug resistance, opportunistic infections and HIV-related organ dysfunction that are critical to a transplant team considering HIV-to-HIV transplantation.
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Affiliation(s)
- B J Boyarsky
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - C M Durand
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - F J Palella
- Department of Medicine, Feinberg School of Medicine, Northwestern University Chicago, Chicago, IL
| | - D L Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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Richterman A, Sawinski D, Reese PP, Lee DH, Clauss H, Hasz RD, Thomasson A, Goldberg DS, Abt PL, Forde KA, Bloom RD, Doll SL, Brady KA, Blumberg EA. An Assessment of HIV-Infected Patients Dying in Care for Deceased Organ Donation in a United States Urban Center. Am J Transplant 2015; 15:2105-16. [PMID: 25976241 DOI: 10.1111/ajt.13308] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 02/05/2015] [Accepted: 03/05/2015] [Indexed: 01/25/2023]
Abstract
Organ transplantation is an acceptable option for human immunodeficiency virus (HIV)-infected patients with end-stage kidney or liver disease. With worse outcomes on the waitlist, HIV-infected patients may actually be disproportionately affected by the organ shortage in the United States. One potential solution is the use of HIV-infected deceased donors (HIVDD), recently legalized by the HIV Organ Policy Equity (HOPE) Act. This is the first analysis of patient-specific data from potential HIVDD, retrospectively examining charts of HIV-infected patients dying in care at six HIV clinics in Philadelphia, Pennsylvania from January 1, 2009 to June 30, 2014. Our data suggest that there are four to five potential HIVDD dying in Philadelphia annually who might yield two to three kidneys and three to five livers for transplant. Extrapolated nationally, this would approximate 356 potential HIVDD yielding 192 kidneys and 247 livers annually. However, several donor risk indices raise concerns about the quality of kidneys that could be recovered from HIVDD as a result of older donor age and comorbidities. On the other hand, livers from these potential HIVDD are of similar quality to HIV-negative donors dying locally, although there is a high prevalence of positive hepatitis C antibody.
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Affiliation(s)
- A Richterman
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - D Sawinski
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - P P Reese
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - D H Lee
- Department of Medicine, Drexel University, Philadelphia, PA
| | - H Clauss
- Department of Medicine, Temple University, Philadelphia, PA
| | - R D Hasz
- Gift of Life Donor Program, Philadelphia, PA
| | - A Thomasson
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - D S Goldberg
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - P L Abt
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - K A Forde
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - R D Bloom
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - S L Doll
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - K A Brady
- Philadelphia Department of Public Health, Philadelphia, PA
| | - E A Blumberg
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Richterman A, Blumberg E. The Challenges and Promise of HIV-Infected Donors for Solid Organ Transplantation. Curr Infect Dis Rep 2015; 17:471. [DOI: 10.1007/s11908-015-0471-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Superior outcomes in HIV-positive kidney transplant patients compared with HCV-infected or HIV/HCV-coinfected recipients. Kidney Int 2015; 88:341-9. [PMID: 25807035 PMCID: PMC5113138 DOI: 10.1038/ki.2015.74] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 01/02/2015] [Accepted: 01/22/2015] [Indexed: 12/22/2022]
Abstract
The prerequisite for an 'undetectable' HIV viral load has restricted access to transplantation for HIV-infected kidney recipients. However, HCV-infected recipients, owing to the historic limitations of HCV therapy in patients with renal disease, are commonly viremic at transplant and have universal access. To compare the effect of HIV, HCV, and HIV/HCV coinfection on kidney transplant patient and allograft outcomes, we performed a retrospective study of kidney recipients transplanted from January 1996 through December 2013. In multivariable analysis, patient (hazard ratio 0.90, 95% confidence interval 0.66-1.24) and allograft survival (0.60, 40-0.88) in 492 HIV patients did not differ significantly from the 117,791 patient-uninfected reference group. This was superior to outcomes in both the 5605 patient HCV group for death (1.44, 1.33-1.56) and graft loss (1.43, 1.31-1.56), as well as the 147 patient HIV/HCV coinfected group for death (2.26, 1.45-3.52) and graft loss (2.59, 1.60-4.19). HIV infection did not adversely affect recipient or allograft survival and was associated with superior outcomes compared with both HCV infection and HIV/HCV coinfection in this population. Thus, pretransplant viral eradication and/or immediate posttransplant eradication should be studied as potential strategies to improve posttransplant outcomes in HCV-infected kidney recipients.
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Stosor V. Organ Transplantation in HIV Patients: Current Status and New Directions. Curr Infect Dis Rep 2013; 15:526-35. [PMID: 24142801 DOI: 10.1007/s11908-013-0381-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Combination antiretroviral therapy has resulted in longer life expectancies in persons living with HIV; however, end organ disease and death from organ failure have become growing issues for this population. With effective therapies for viral suppression, HIV is no longer considered an absolute contraindication to organ transplantation. Over the past decade, studies of transplantation in patients with HIV have had encouraging results such that patients with organ failure are pursuing transplantation. This review focuses on the current status of organ transplantation for HIV-infected persons.
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Affiliation(s)
- Valentina Stosor
- Divisions of Infectious Diseases and Organ Transplantation and Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, 645 North Michigan Avenue, Suite 900, Chicago, IL, 60611, USA,
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Mgbako O, Glazier A, Blumberg E, Reese PP. Allowing HIV-positive organ donation: ethical, legal and operational considerations. Am J Transplant 2013; 13:1636-42. [PMID: 23758835 PMCID: PMC3808247 DOI: 10.1111/ajt.12311] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 04/11/2013] [Accepted: 04/16/2013] [Indexed: 01/25/2023]
Abstract
Case reports of kidney transplantation using HIV-positive (HIV+) donors in South Africa and advances in the clinical care of HIV+ transplant recipients have drawn attention to the legal prohibition of transplanting organs from HIV+ donors in the United States. For HIV+ transplant candidates, who face high barriers to transplant access, this prohibition violates beneficence by placing an unjustified limitation on the organ supply. However, transplanting HIV+ organs raises nonmaleficence concerns given limited data on recipient outcomes. Informed consent and careful monitoring of outcome data should mitigate these concerns, even in the rare circumstance when an HIV+ organ is intentionally transplanted into an HIV-negative recipient. For potential donors, the federal ban on transplanting HIV+ organs raises justice concerns. While in practice there are a number of medical criteria that preclude organ donation, only HIV+ status is singled out as a mandated exclusion to donation under the National Organ Transplant Act (NOTA). Operational objections could be addressed by adapting existing approaches used for organ donors with hepatitis. Center-specific outcomes should be adjusted for HIV donor and recipient status. In summary, transplant professionals should advocate for eliminating the ban on HIV+ organ donation and funding studies to determine outcomes after transplantation of these organs.
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Affiliation(s)
- O Mgbako
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - E Blumberg
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,University of Pennsylvania Perelman School of Medicine, Division of Infectious Diseases, Department of Medicine, Philadelphia, PA
| | - PP Reese
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,University of Pennsylvania Perelman School of Medicine, Department of Biostatistics and Epidemiology, Philadelphia, PA,University of Pennsylvania Perelman School of Medicine, Renal Division, Department of Medicine, Philadelphia, PA
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HIV-infected kidney graft recipients managed with an early corticosteroid withdrawal protocol: clinical outcomes and messenger RNA profiles. Transplantation 2013; 95:711-20. [PMID: 23503504 DOI: 10.1097/tp.0b013e31827ac322] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The outcome of HIV-infected kidney transplant recipients managed with an early corticosteroid withdrawal protocol is not known. METHODS Eleven consecutive HIV-infected patients with undetectable plasma HIV RNA and more than 200/mm CD4 T cells underwent deceased-donor (n=8) or living-donor (n=3) kidney transplantation at our center. All were managed with an early corticosteroid withdrawal protocol; 9 of 11 received antithymocyte globulin and 2 received basiliximab induction. We analyzed patient and graft outcomes, acute rejection rate, HIV progression, BKV replication, infections, and urinary cell mRNA profiles. RESULTS The median (range) follow-up was 44.5 (26-73) months. The incidence of acute rejection was 9% at 1 year and the patient and allograft survival rates were 100% and 91%, respectively. Estimated glomerular filtration rate at 1 year (mean ± SD) was 78 ± 39 mL/min/1.73 m. Plasma HIV RNA was undetectable at 24 months and none had BKV replication. Six of the 11 kidney recipients developed eight infections requiring hospitalization. Urinary cell levels of mRNA for complement components and complement regulatory proteins, cell lineage-specific proteins CD3, CD4, CD8, CTLA4, Foxp3, chemokine IP-10, cytotoxic perforin and granzyme B, and BKV VP1 mRNA were not different (P>0.05) between HIV-infected patients and HIV-negative recipients (n=22) with stable graft function and normal biopsy results. CONCLUSION An early steroid withdrawal regimen with antithymocyte globulin induction was associated with excellent graft and patient outcomes in HIV-infected recipients of kidney allografts. Their urinary cell mRNA profiles are indistinguishable from those of HIV-negative patients with stable graft function and normal biopsy results.
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Abstract
Antiretroviral therapy has been immensely successful in reducing the incidence of opportunistic infections and death after HIV infection. This has resulted in heightened interest in noninfectious comorbidities including kidney disease. Although HIV-associated nephropathy, the most ominous kidney disease related to the direct effects of HIV, may be prevented and treated with antiretrovirals, kidney disease remains an important issue in this population. In addition to the common risk factors for kidney disease of diabetes mellitus and hypertension, HIV-infected individuals have a high prevalence of other risk factors, including hepatitis C and exposure to antiretrovirals and other medications. Therefore, the differential diagnosis is vast. Early identification (through efficient screening) and prompt treatment of kidney disease in HIV-infected individuals are critical to lead to better outcomes. This review focuses on clinical and epidemiological issues, treatment strategies (including dialysis and kidney transplantation), and recent advances among kidney disease in the HIV population.
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