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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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2
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Milosh B, Bugaighis M, Cervia J. Systematic review of the impact of protease-inhibitor-based combination antiretroviral therapy on renal transplant outcomes in recipients living with HIV infection. J Investig Med 2024:10815589241252595. [PMID: 38666448 DOI: 10.1177/10815589241252595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
Advances in human immunodeficiency virus (HIV) treatment, including combination antiretroviral therapy (cART), have transformed HIV into a chronic condition. Kidney diseases cause morbidity and mortality in patients living with HIV (PLWH), though cART has permitted kidney transplants with acceptable post-transplant graft and patient survival. Risk of allograft rejection remains high, which may be related to interactions between cART, specifically protease inhibitors (PI), and immunosuppressants prescribed post-transplant. This systematic review evaluates renal transplant outcomes in PLWH treated with PI- vs non-PI-based cART. A search strategy was generated with terms related to renal transplant, HIV, and cART and run on PubMed, Embase, Scopus, and Cochrane. Studies were evaluated using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines on Covidence by two reviewers and then evaluated for bias. Of 803 studies, 9 were included. Included papers were prospective or retrospective cohort studies or chart reviews of adult patients. Outcome measures included acute graft rejection, graft survival, and patient survival. One study had significant results demonstrating that PI-based therapy was correlated with increased graft rejection rates. Two studies demonstrated significant graft survival benefit to non-PI-based therapy, while one demonstrated significant benefit to PI-based therapy. Two studies found significant patient survival benefit to non-PI-based therapy. For each outcome measure, remaining data suggested improved outcomes with non-PI-based therapies without achieving statistical significance. The results demonstrate superior outcomes in PLWH taking non-PI-based cART, though the paucity of significant results suggests that PLWH who require PI-based cART for virological control may continue their regimen safely post-kidney transplant.
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Affiliation(s)
- Brooke Milosh
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Mona Bugaighis
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Joseph Cervia
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Division of Infectious Diseases, Departments of Medicine and Pediatrics, Center for AIDS Research and Treatment, Northwell Health, New Hyde Park, NY, USA
- HealthCare Partners IPA and MSO, Garden City, NY, USA
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3
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Chandran S, Stock PG, Roll GR. Expanding Access to Organ Transplant for People Living With HIV: Can Policy Catch Up to Outcomes Data? Transplantation 2024; 108:874-883. [PMID: 37723620 DOI: 10.1097/tp.0000000000004794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Advances in antiretroviral and immunosuppressive regimens have improved outcomes following solid organ transplantation in people living with HIV (PLWH). The HIV Organ Policy and Equity Act was conceived to reduce the discard of HIV-positive organs and improve access to transplant for PLWH. Nevertheless, PLWH continue to experience disproportionately low rates of transplant. This overview examines the hurdles to transplantation in PLWH with end-organ disease, the potential and realized impact of the HIV Organ Policy and Equity Act, and changes that could permit expanded access to organ transplant in this population.
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Affiliation(s)
- Sindhu Chandran
- Department of Medicine, University of California-San Francisco (UCSF), San Francisco, CA
| | - Peter G Stock
- Department of Surgery, University of California-San Francisco (UCSF), San Francisco, CA
| | - Garrett R Roll
- Department of Surgery, University of California-San Francisco (UCSF), San Francisco, CA
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Lynch EN, Russo FP. Liver Transplantation in People Living with HIV: Still an Experimental Procedure or Standard of Care? Life (Basel) 2023; 13:1975. [PMID: 37895356 PMCID: PMC10608432 DOI: 10.3390/life13101975] [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: 08/23/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023] Open
Abstract
Liver transplantation (LT) is the only curative treatment for various liver diseases, including acute liver failure, end-stage liver disease, and selected unresectable liver malignancies. Combination antiretroviral therapy has improved outcomes for people living with HIV (PLWH), transforming the status of acquired immune deficiency syndrome from a fatal disease to a chronic and manageable condition. These powerful antiviral therapies have not only increased the number of HIV+ enlisted patients by improving their survival but also made the use of HIV+ organs a viable option. In this review, we summarise current knowledge on the peculiarities of liver transplantation in PLWH. In particular, we focus on the indications, contraindications, specific considerations for treatment, and outcomes of LT in PLWH. Finally, we present available preliminary data on the use of HIV+ liver allografts.
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Affiliation(s)
- Erica Nicola Lynch
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology/Multivisceral Transplant Section, Padua University Hospital, 35128 Padua, Italy;
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50134 Florence, Italy
| | - Francesco Paolo Russo
- Department of Surgery, Oncology and Gastroenterology, Gastroenterology/Multivisceral Transplant Section, Padua University Hospital, 35128 Padua, Italy;
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Oloruntoba-Sanders O, Tanna SD. Evaluation and management of post-transplant infections for the hepatologist. Clin Liver Dis (Hoboken) 2023; 21:173-177. [PMID: 37361254 PMCID: PMC10287139 DOI: 10.1097/cld.0000000000000056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/25/2023] [Indexed: 06/28/2023] Open
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Novruzbekov MS, Gulyaev VA, Mazus AI, Ivannikov EV, Yadrikhinskaya MS, Lutsyk KN, Olisov OD, Akhmetshin RB, Magomedov KM, Kazymov BI, Akhmedov AR, Alekberov KF, Yaremin BI. First experience of liver transplantation for HIV-positive patients in Russia. BULLETIN OF THE MEDICAL INSTITUTE "REAVIZ" (REHABILITATION, DOCTOR AND HEALTH) 2022. [DOI: 10.20340/vmi-rvz.2022.6.tx.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The article presents the results of liver transplantation in five HIV-infected recipients with irreversible liver damage. It is shown that four of them survived in the long-term period and are observed in a stable condition, and the only death in the recipient was not related to the HIV infection. The experience in the treatment of these patients was summarized. Analysis of the first results of liver transplantation in HIV-infection in Russia shows its validity and clinical efficacy. The only lethal case is connected with the initial extremely grave condition of the recipient and his age. Two cases of surgical traumatism, lack of consistent vaccination in the preoperative period, as well as lack of patients with hepatocellular cancer, small number of observations are obvious drawbacks of our first experience and should be corrected in the future. The success of a complex and multidisciplinary program of organ transplantation in HIV infection is impossible without participation of HIV-infectionists in the transplantation team.
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Affiliation(s)
- M. S. Novruzbekov
- Sklifosovsky Research Institute of Emergency Medicine; Pirogov Russian National Research Medical University
| | - V. A. Gulyaev
- Sklifosovsky Research Institute of Emergency Medicine
| | | | | | | | - K. N. Lutsyk
- Sklifosovsky Research Institute of Emergency Medicine
| | - O. D. Olisov
- Sklifosovsky Research Institute of Emergency Medicine
| | | | | | - B. I. Kazymov
- Sklifosovsky Research Institute of Emergency Medicine
| | | | | | - B. I. Yaremin
- Sklifosovsky Research Institute of Emergency Medicine; Pirogov Russian National Research Medical University
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Glicklich D, Nog R. HIV in kidney transplantation. Curr Opin Organ Transplant 2022; 27:64-69. [PMID: 34890378 DOI: 10.1097/mot.0000000000000949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to describe recent developments in renal transplantation for HIV-positive recipients, especially the HIV Organ Policy Equity (HOPE) trial results. RECENT FINDINGS HOPE trial data show that HIV-positive D+/R+ results are excellent and similar to D-/R+ in patients controlled on antiretroviral therapy (ART). Patients coinfected with hepatitis C or B virus now have effective treatment available. As pretransplant evaluation and post-transplant management is more complex in HIV-positive individuals early referral is important and coordination of evaluation and care with an infectious disease specialist is critical. HIV coordinated care services should be involved for best outcomes. HIV-positive renal transplant recipients have an increased risk of rejection and evidence suggests that standard lymphocyte depletion induction and maintenance immunosuppression be employed. Cardiovascular risk reduction and surveillance and attention to metabolic bone disease are important for HIV-positive renal transplant recipients. SUMMARY HIV-positive to HIV-positive renal transplantation has been established as well tolerated and successful. Further efforts are needed to expand access to transplantation in this population. VIDEO ABSTRACT http://links.lww.com/MOT/A29.
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Affiliation(s)
- Daniel Glicklich
- Westchester Medical Center, New York Medical College, Westchester, New York, USA
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Abstract
Individuals with HIV are at increased risk for ESKD. Kidney transplantation is the best treatment for ESKD in the HIV+ population. Despite reduced access to transplantation, patients who are HIV+ have excellent outcomes and clearly benefit from receiving one. Common post-transplant complications and management concerns, including the optimal antiretroviral regimen, immunosuppression protocols, infectious prophylaxis, hepatitis C coinfection, metabolic complications, and malignancy are all discussed.
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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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Morales MK, Lambing T, Husson J. Review: Evaluation and Management of the HIV/HCV Co-Infected Kidney or Liver Transplant Candidate. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00220-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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10
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Heart or lung transplant outcomes in HIV-infected recipients. J Heart Lung Transplant 2019; 38:1296-1305. [PMID: 31636044 DOI: 10.1016/j.healun.2019.09.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 09/13/2019] [Accepted: 09/19/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Limited published data exist on outcomes related to heart and/or lung transplantation in human immunodeficiency virus (HIV)-infected individuals. METHODS We conducted a multicenter retrospective study of heart and lung transplantation in HIV-infected patients and describe key transplant- and HIV-related outcomes. RESULTS We identified 29 HIV-infected thoracic transplant recipients (21 heart, 7 lung, and 1 heart and/or lung) across 14 transplant centers from 2000 through 2016. Compared with an International Society for Heart and Lung Transplantation registry cohort, we demonstrated similar 1-, 3-, and 5-year patient and allograft survivals for each organ type with a median follow up of 1,064 (range, 184-3,745) days for heart and 1,540 (range, 116-3,206) days for lung recipients. At 1 year, significant rejection rates were high (62%) for heart transplant recipients (HTRs). Risk factors for rejection were inconclusive, likely because of small numbers, but may be related to cautious early immunosuppression and infrequent use of induction therapy. Pulmonary bacterial infections were high (86%) for lung transplant recipients (LTRs). Median CD4 counts changed from baseline to 1 year from 399 to 411 cells/µl for HTRs and 638 to 280 cells/µl for LTRs. Acquired immunodeficiency syndrome-related events, including infections and malignancies, were rare. Rates of severe renal dysfunction suggest a need to modify nephrotoxic anti-retrovirals and/or immunosuppressants. CONCLUSIONS HIV-infected HTRs and LTRs have similar survival rates to their HIV-uninfected counterparts. Although optimal immunosuppression is not defined, it should be at least as aggressive as that for HIV-uninfected recipients. Such data may help pave the way for the use of hearts and lungs from HIV-infected donors in HIV-infected recipients through HIV Organ Policy Equity Act protocols.
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Blumberg EA, Rogers CC. Solid organ transplantation in the HIV-infected patient: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13499. [PMID: 30773688 DOI: 10.1111/ctr.13499] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/12/2019] [Indexed: 12/14/2022]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the management of transplantation in HIV-infected individuals. Transplantation has become the standard of care for patients with HIV and end-stage kidney or liver disease. Although less data exist for thoracic organ and pancreas transplantation, it is likely that transplantation is also safe and effective for these recipients as well. Despite what is typically a transient decline in CD4+ T lymphocytes, HIV remains well controlled and infection risks are similar to those of HIV-uninfected transplant recipients. The availability of effective directly active antivirals for the treatment of Hepatitis C is likely to improve outcomes in HIV and HCV co-infected individuals, a population previously noted to have decreased survival. Drug interactions remain an important consideration, and integrase inhibitor-based regimens are preferred due to the absence of interactions with calcineurin and mTOR inhibitors. Additionally, despite the use of more potent immunosuppression, rejection rates exceed those found in HIV-uninfected recipients. Ongoing research evaluating HIV-positive organ donors may provide support for utilizing these donors for HIV-positive patients in need of transplantation.
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Affiliation(s)
- Emily A Blumberg
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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12
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Ngutshane BS, Sparaco A, Mayne ES. Epidemiological and Immunological Characteristics of HIV-Infected Patients on the Cadaveric Kidney Donor Waiting List at the Johannesburg Renal Transplant Program. AIDS Res Hum Retroviruses 2019; 35:388-392. [PMID: 30618265 DOI: 10.1089/aid.2018.0193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
HIV infection was previously considered an exclusion criterion for renal dialysis and transplant. Recent research has prompted policy changes, allowing for transplantation in this subgroup of patients. Theoretical risks with transplantation include the immune dysregulation associated with post-transplantation immunosuppression and immune activation with possible organ rejection. Assessments for eligibility to renal transplantation rely on a point system, which allocates points based on a patient's age, previous transplants, and time on the waiting list as well as panel reactive antibodies among other parameters. This study aimed at quantifying and defining the clinically relevant characteristics of HIV-infected patients on the cadaveric donor waiting list on the Johannesburg renal transplant program. Clinical records for patients on the transplant list from November 2016 to October 2017 were accessed from existing databases and clinical records. A total of 248 patients were analyzed during the study period. There were a total of 215 HIV-uninfected patients, and 33 HIV-infected patients were on the waiting list. The median age for patients at listing was 39 years (interquartile range 29-47). There were no significant differences in the median age of listing between the HIV-infected and HIV-uninfected groups (p = .7). Hypertension was the most common cause of renal failure in both study groups. The study did not show any significant differences in age or immunological characteristics between the HIV-infected and HIV-uninfected groups. This suggests that for immunological risk stratification purposes, these two groups of patients could be considered equivalent. A possible explanation for this could be that antiretroviral therapy has a significant role in mitigating the effect of the virus on the immune system. Further studies looking at a larger study population are required to corroborate these findings. These data do provide reassurance that HIV-infected patients are suitable candidates for transplantation.
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Affiliation(s)
- Bongane S. Ngutshane
- Department of Cardiothoracic Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Anna Sparaco
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Renal Transplant Unit, Charlotte Maxeke Johannesburg Academic Hospital, Wits Donald Gordon Academic Centre, Johannesburg, South Africa
| | - Elizabeth S. Mayne
- Department of Immunology, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
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Sawinski D, Blumberg EA. Infection in Renal Transplant Recipients. CHRONIC KIDNEY DISEASE, DIALYSIS, AND TRANSPLANTATION 2019. [PMCID: PMC7152484 DOI: 10.1016/b978-0-323-52978-5.00040-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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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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