HIV Transplant Donors: Expanding Opportunities to Save HIV Patient Lives

• Published in: The clinical advisor Vol. 23; no. 10; pp. 13 - 16
• Main Authors: Ochieng, Eudiah, Daitch, Lisa
• Format: Magazine Article
• Language: English
• Published: Hawthorne Haymarket Media, Inc 01.12.2020
• Subjects: Blood & organ donations; Case studies; Chronic illnesses; Disease transmission; Drug dosages; Drug interactions; Drug therapy; Hepatitis; HIV; Human immunodeficiency virus; Infections; Kidney transplants; Life expectancy; Liver diseases; Liver transplants; Mortality; Patients; Pharmacokinetics; United States > US; South Africa
• ISSN: 1524-7317

End-stage organ diseases, such as end-stage renal disease (ESRD) and liver disease from hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infection, are now the primary causes of mortality in HIV-positive patients.2,3 Although the incidence of ESRD has been declining, the prevalence has been increasing among patients with HIV.4,5 People living with HIV have an incidence of ESRD that is 2 to 4 times higher than that of people without HIV5 Most patients with ESRD are treated with dialysis, but solid organ transplantation is the most effective treatment to improve quality of life and reduce mortality.5,6 More than 109,000 Americans are on a waitlist for an organ transplant.7 The organ shortage has led researchers to critically re-evaluate organ sources that previously were considered too risky.8,9 This has led to a number of advances in transplantation, such as the use of organs from HIV-positive donors for HIV-positive recipients and, more recently, a life-saving partial liver transplant from an HIV-positive mother to her HIV-negative child (See Case Study).10 These advances have the potential to improve the chance of survival for HIV-positive patients on organ transplantation waitlists. Evolution of Transplantation in HIV+ Patients The HIV Organ Policy Equity (HOPE) Act11 was proposed in 2011 after successful kidney and liver transplants were performed from HIV-positive cadavers to HIV-positive recipients in South Africa.12,13 In those early cases, there was no reported evidence of HIV superinfection; organ rejection rates at 1 and 3 years were 8% and 25%, respectively, and 1 of the 4 recipients developed idiopathic glomerulopathy.3,4,12,13 Under the HOPE Act, implemented in November 2013, HIV-positive donor to HIV-positive recipient transplants are permitted in the United States for clinical research under specific guidelines by the National Institutes of Health (NIH).3,8,10 The first such transplants in the United States were performed in 2016 at Johns Hopkins University Medical Center.2,3,10 In 2019, an HIV-positive living donor donated a kidney to an HIVpositive recipient at Johns Hopkins University Medical Center.8 Under the HOPE Act, donor selection, immunosuppression management, and postoperative management are reviewed carefully for both the donor and recipient. The potential for increased toxicity and drug interactions should be considered carefully when determining optimal immunosuppressive therapy (Table).17 Maintenance of immunosuppression can be achieved with calcineurin inhibitors (CNIs), but drug interactions between CNIs and some ART agents, such as protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs), can create a challenge in maintenance of immunosuppression.2,12,13 Belatacept is an immunosuppressive agent that is organ safe, does not interact with ART, and has the added benefits of antiviral activity against HIV2,17,18 Before a transplant, a patient should be on a stable ART regimen. Black patients have increased rates ofglomerulopathy including HIV-associated nephropathy.3,5 Factors Associated With Rejection Management of the transplanted organ can be complex due to drug interactions and an increased risk of rejection.8 Compared with HIV-negative recipients, HIV-positive recipients have an approximately 3 times higher risk for acute rejection.13 Muller et al examined cumulative survival rates among 27 patients with an HIV-positive to HIV-positive kidney transplant at 1, 3, and 5 years; results were 84%, 84%, and 74%, respectively.