HIV testing in patients with end stage renal disease

[Organ transplantation in human immunodeficiency virus-infected patients. Results of a survey in German transplantation centres]

BACKGROUND

Despite considerable advances following the introduction of highly active antiretroviral therapy, organ transplantation is usually denied categorically for human immunodeficiency virus (HIV) patients, and it is presented in German transplantation law as a contraindication. Today, this should be questioned critically.

METHOD

A survey at all 87 German transplant centres was done concerning (1) how many HIV-positive patients were transplanted before and after February 2000, (2) willingness of the centres to transplant HIV-infected patients in the future, and (3) course of transplanted HIV patients so far.

RESULTS

With a response rate of 78%, 39% of the questioned centres were accepting HIV patients in the future for transplantation, and 39% rejected this. Twenty percent voted for individual case decision. Three centres had practiced liver transplantation in 11 patients.

CONCLUSION

The decision to transplant HIV-positive patients in Germany is mostly based on individual cases and not refused in general. However, prospective studies on this issue are justified and needed.

Blood-borne virus infections in dialysis units--a review

Hepatitis outbreaks in haemodialysis unit patients and staff were reported in the late 1960s. In 1972, the Rosenheim report in the UK established guidelines which included routine tests for hepatitis B surface antigen and isolation facilities for dialysing patients with hepatitis B virus which resulted in a dramatic fall in cases of hepatitis. However, since these guidelines were introduced, other blood-borne viruses, notably HCV and HIV have been discovered, and failures of infection control practices still lead to outbreaks of HBV in haemodialysis units. The prevalence of HCV in dialysis patients varies considerably throughout the world, with reported prevalence ranging from 3.9% to 71%. The number of blood transfusions and the length of time on dialysis have consistently been associated with HCV prevalence. Several reports provide evidence of patient-to-patient HCV transmission with environmental blood contamination the most significant factor in intra-unit transmission. There is no evidence that HCV has been transmitted by re-use of dialysis machines but being dialysed next to an HCV positive patient is associated with a significant risk of HCV acquisition. Several studies have shown that dialysing HCV positive patients in a separate unit or in a defined sector of a dialysis unit significantly reduces nosocomial HCV infection. HGV is prevalent in dialysis units where there is evidence of transmission to patients but no evidence of associated symptoms. HIV is infrequently transmitted in dialysis units and several units treating many HIV-positive patients have shown no evidence of transmission. Careful attention needs to be paid to infection control procedures and regular virological testing.

Should all human immunodeficiency virus-infected patients with end-stage renal disease be excluded from transplantation? The views of U.S. transplant centers

BACKGROUND

Human immunodeficiency virus (HIV)-infected patients have generally been excluded from transplantation. Recent advances in the management and prognosis of these patients suggest that this policy should be reevaluated.

METHODS

To explore the current views of U.S. transplant centers toward transplanting asymptomatic HIV-infected patients with end-stage renal disease, a written survey was mailed to the directors of transplantation at all 248 renal transplant centers in the United States.

RESULTS

All 148 responding centers said they require HIV testing of prospective kidney recipients, and 84% of these centers would not transplant an individual who refuses HIV testing. The vast majority of responding centers would not transplant a kidney from a cadaveric (88%) or a living donor (91%) into an asymptomatic HIV-infected patient who is otherwise a good candidate for transplantation. Among the few centers that would consider transplanting an HIV-infected patient, not a single center had performed such a transplant in the year prior to the survey. Most centers fear that transplantation in the face of HIV infection would be harmful to the individual, and some believe that it would be a waste of precious organs.

CONCLUSIONS

The great majority of U.S. renal transplant centers will not transplant kidneys to HIV-infected patients with end-stage renal disease, even if their infection is asymptomatic. However, advances in the management of HIV infection and a review of relevant ethical issues suggest that this approach should be reconsidered.

The treatment of non-HIV-related conditions in newborns at risk for HIV: a survey of neonatologists

OBJECTIVES

The purpose of this study was to examine attitudes of neonatologists about treatment of conditions unrelated to the human immunodeficiency virus (HIV) for critically ill newborns at risk for HIV.

METHODS

Questionnaires were mailed to the 1508 members of the Section on Perinatal Medicine of the American Academy of Pediatrics; 63% completed the survey (n = 951). The survey included structured questions about treatment for hypothetical cases and open-ended questions eliciting reasons for decisions.

RESULTS

Differences in recommendations for treatment by both maternal and infant HIV status were substantial and statistically reliable. For example, 98% of respondents recommended life-saving cardiac surgery for a neonate with no risk for HIV, but only 93% recommended such surgery for a child of an HIV-positive mother; only 50% recommended the same surgery for a newborn known to be infected. The corresponding figures for chronic dialysis were 91%, 61%, and 26%. Most expected diminished quality of life for both infected and uninfected children of HIV-positive mothers.

CONCLUSIONS

Recommendations about life-sustaining treatment for non-HIV-related conditions varied by HIV status. These data on physician attitudes raise the possibility that infants labeled as HIV positive, whether infected or not, may suffer discrimination.