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Johns Hopkins Team Performs Pioneering HIV+ to HIV+ Liver and Kidney Transplants

Doctors at Johns Hopkins announced that they recently performed the first-ever liver transplant and the first kidney transplant in the U.S. from an HIV-positive donor to a recipient living with HIV, made possible by the 2013 HIV Organ Policy Equity (HOPE) Act. Both transplants were successful and the patients are doing "extremely well," infectious disease specialist Christine Durand said at a March 30 press conference.

"This is an unbelievably exciting day for our hospital and our team, but more importantly for patients living with both HIV and end-stage organ disease," said Johns Hopkins School of Medicine transplant surgeon Dorry Segev. "For these individuals, this could mean a new chance at life."

"This is an advancement that will benefit everyone on the [waiting] list, including people without HIV" by expanding the total pool of door organs, Durand added.

Early in the epidemic, when HIV/AIDS was almost always fatal, Congress passed legislation banning transplants of organs from donors infected with HIV.

Over the years, however, as effective antiretroviral therapy (ART) emerged and HIV became a manageable disease in treated patients, researchers began performing transplants in HIV-positive recipients using organs from HIV-negative donors. Studies have shown that transplant outcomes for selected HIV-positive people on suppressive ART with CD4 T-cell counts >200 cells/mm³ are nearly as good as those of HIV-negative recipients.

Segev explained that the Johns Hopkins team had been doing successful transplants for HIV-positive people for 6 years, growing increasingly frustrated that there were thousands of patients with HIV in need of transplants on the waiting list, with a high risk of death, while at the same time "potentially perfectly good organs" from HIV-infected donors were being thrown away.

Therefore, Segev and colleagues did a study of the potential impact of legalizing transplantation of HIV-infected organs, estimating that around 500-600 HIV-positive people who died each year could potentially be organ donors for more than 1000 HIV-positive recipients. "In the current era of HIV management, a legal ban on the use of these organs seems unwarranted and likely harmful," they wrote.

Segev worked with other transplant and HIV experts and advocates to design and pass the HOPE Act, which President Barack Obama signed in November 2013. After that, it took a couple more years to develop protocols and change the policies of the Health Resources and Services Administration (HRSA) and the United Network for Organ Sharing, which manages organ procurement and distribution in the U.S., he said at the press conference.

Durand gave an update on the status of the first HIV-positive to HIV-positive kidney transplant in the U.S. (this procedure has previously been done in South Africa) and the first positive to positive liver transplant in the world. Organs for both transplants came from the same HIV-positive deceased donor. The recipients wished to remain anonymous

The kidney transplant recipient, who had been living with HIV for more than 30 years, developed kidney failure related to hypertension and autoimmune disease that required dialysis. Though listed at multiple transplant centers, he had been on the waiting list for years and was the first to enroll in the Johns Hopkins HIV-positive transplant study. The patient received a new kidney a couple weeks ago, the surgery was without complications, the kidney started working immediately, and the patient is back home and doing well, Durand reported.

The liver transplant recipient had been living with HIV for over 25 years and had developed liver disease due to hepatitis C virus (HCV) coinfection. Although cured of HCV with new antiviral drugs, the patient already had severe liver damage and had progressed to liver failure. Thanks to the change in the law, the patient was able to receive an organ while still well enough to benefit. This patient is still in the hospital and the new liver is functioning "extremely well," Durand said.

Durand described a unique risk of transplantation from an HIV-positive donor: Since the recipient is exposed to a new strain of HIV from the infected organ and could potentially develop a secondary infection, doctors must consider whether the donor has resistant virus and "take into account matching regimens and matching resistance patterns," she explained.

Segev said centers that want to do HIV-positive to HIV-positive transplants should have experience doing transplants for HIV-positive people using organs from uninfected donors. He said dozens of centers have this experience, and they have put together a consortium of about 30 hospitals so far, with which Johns Hopkins will share safety and other protocols. Next, the team plans to study transplants from HIV-positive living donors.

Segev noted that the HOPE Act expands the donor pool for HIV-positive people on the transplant waiting list but does not limit them to organs from HIV-positive donors. They can wait for an uninfected organ if they wish, but if they want to get a transplant faster they can also consider HIV-positive organs.

"For those living with HIV this is a very exciting time. Instead of having a very high risk of death on the waiting list, now every HIV-positive donor represents potential lives saved," Segev concluded. "Not only does HOPE make it possible for HIV-positive people to receive transplants, it also makes it possible for those with HIV to donate organs, which removes one of the major stigmas."

"As we all know, HIV is a stigma and people with the disease are unfortunately at times treated differently," the family of the HIV-positive donor said in a statement. "She was able to leave this world helping those underdogs she fought so hard for."

"Ending a long-standing ban on transplants with HIV positive organs, even for research purposes, HOPE modernized outdated federal law to reflect the current medical understanding of HIV infection," HIV Medicine Association chair Carlos del Rio said in a media statement. "For patients living with HIV, deceased donors with the same infection represent a unique source of organs holding the potential to save the lives of hundreds of HIV-infected patients struggling with liver and kidney failure each year."

A recording of the press conference is available at https://webcast.jhu.edu/Mediasite/Play/9eb51c9169324757a14185211a7c260c1d.

3/30/16

Sources

Johns Hopkins Medicine. Media Briefing to Announce First-Ever Liver Transplant from HIV-Positive Donor. Media advisory. March 30, 2016.

Johns Hopkins Medicine. Johns Hopkins Approved to Perform First HIV-Positive to HIV-Positive Organ Transplants in U.S. Press release. February 8, 2016.

HIVMA Hails the First U.S. HIV+ to HIV+ Organ Transplant. Media statement. March 30, 2016.