WASHINGTON — The introduction of highly active antiretroviral therapy, more effective prophylactic regimens, and improvements in surgical technique and antirejection therapy have made solid organ transplantation a possibility for HIV-infected patients, said Marla J. Keller, M.D., at a meeting sponsored by the National Kidney Foundation.
Based on the most recent analysis from an ongoing, multicenter, prospective, observational study, survival among HIV-infected kidney transplant patients at 1 year was 93.8%. For comparison, the 1-year survival for kidney transplant patients in the Organ Procurement and Transplantation Network database was 95.6% (1999–2001), said Dr. Keller of Mount Sinai School of Medicine in New York.
This analysis included 29 patients, 18 of whom received kidney transplants. The patients were enrolled in the study between 2000 and 2003. Potential kidney recipients were included in the study if they had CD4 T-cell counts of at least 200, HIV RNA less than 50 copies/mL, and no history of opportunistic infections. Patients are being followed for up to 5 years.
Initial immunosuppressive therapy included cyclosporine or tacrolimus in combination with prednisone, with or without mycophenolate mofetil. Rejections were managed with steroid pulses, changing calcineurin inhibitors or doses, and/or adding sirolimus and/or Thymoglobulin. All antiretroviral drugs were allowed, though AZT and stavudine (d4T) use was minimized. Standard transplant prophylaxis was used for several opportunistic organisms.
Most of the kidney transplant recipients (17) were male. There were slightly more white patients (10) than African American patients (8). Kidney donors were fairly evenly split: five related, living; three unrelated, living; six deceased; and four high infectious risk, deceased. Organs from deceased donors were considered high infectious risk if they were serologically negative for HIV and hepatitis B and C but the donor might have engaged in behavior putting them at risk for recent acquisition. The median baseline CD4 T-cell count was 439 cells/mm
One opportunistic infection occurred in a diabetic patient, who developed Candida esophagitis. Surprisingly, 12 kidney recipients (67%) had graft rejection, mostly of the early acute cellular type. Seven patients received Thymoglobulin in response to eight rejection episodes. The 1-year cumulative rejection estimate was 52%, said Dr. Keller. One kidney transplant recipient died because of congestive heart failure, and two patients had graft loss—one because of rupture from severe acute rejection and one due to chronic allograft nephropathy.