People with HIV Have Good Kidney Transplant Outcomes

		SUMMARY: HIV positive people can safely undergo kidney transplantation and achieve survival outcomes nearly as good as those of HIV negative individuals, according to research published in the November 18, 2010 New England Journal of Medicine. Nearly 90% of HIV positive kidney recipients were still alive 3 years after transplantation, with no increase in HIV-related complications, but this group did have a higher than expected rate of organ rejection.

By Liz Highleyman

Early in the AIDS epidemic, most clinicians considered people with HIV to be poor candidates for organ transplants, due to comprised immune function and limited life expectancy. Since the advent of effective combination antiretroviral therapy (ART) in the mid-1990s, though, a growing number of centers now perform transplants for this population.

Peter Stock and Michele Roland from the University of California at San Francisco and colleagues conducted a prospective, non-randomized trial of kidney transplantation in HIV positive patients with undetectable viral load on ART and CD4 T-cell counts of at least 200 cells/mm3.

The ability of people with HIV to undergo kidney transplantation is important because end-stage renal disease (ESRD) is relatively common in this population, especially among black patients, the study authors noted as background.

Between November 2003 and June 2009, a total of 150 HIV positive patients at 19 medical centers underwent kidney transplantation. Most (78%) were men, the median age was 46 years, and 69% were black. The median CD4 count at the time of transplantation was 524 cells/mm3.

Participants were followed for a median of 1.7 years. Post-transplant management was provided in accordance with study protocols that included guidelines for prophylaxis against opportunistic infections, indications for biopsy, use of immune-suppressing medications to prevent organ rejection, and continued use of ART.

Results

	1 year after transplantation, the patient survival rate was 94.6%.
	At 3 years, this rate remained high, at 88.2%.
	Rates of graft, or donor kidney, survival were 90.4% at 1 year and 73.7% at 3 years.
	However, organ rejection occurred more often than expected, with 49 patients (33%) experiencing 67 acute rejection episodes.
	Based on this finding, the rejection rate was estimated at 31% by 1 year and 41% by 3 years.
	In a multivariate analysis, patients treated for organ rejection and those receiving anti-thymocyte globulin induction therapy were significantly more likely to experience graft loss (hazard ratios 2.8 and 2.5, respectively).
	Patients who received kidneys from living donors rather than cadavers experienced significantly less graft loss (hazard ratio 0.2).
	In general, HIV infection remained well controlled, with stable CD4 counts and few HIV-associated complications.
	7 patients, however, progressed to AIDS (CD4 count < 200 cells/mm3 or AIDS-defining opportunistic illness).
	Use of anti-thymocyte globulin was linked to greater CD4 cell loss.
	57 patients (38%) experienced a total of 140 reported infections that required hospitalization (69% bacterial, 9% fungal, 6% viral, and 1% protozoal).

"In this cohort of carefully selected HIV-infected patients, both patient- and graft-survival rates were high at 1 and 3 years, with no increases in complications associated with HIV infection," the study authors concluded.

They noted that, in general, patient and graft survival rates in this study were a bit lower than rates reported in the national transplant database for all kidney transplant recipients, but higher than those for transplant recipients age 65 or older.

But the rate of kidney rejection in this study was about 2 to 3 times higher than usual. Even though early organ rejection could often be managed, thus saving the kidney, the researchers said, "The unexpectedly high rejection rates are of serious concern and indicate the need for better immunotherapy."

In an accompanying editorial, Lynda Szczech from Duke University Medical Center wrote that, "Stock and his colleagues have now challenged assumptions that seemed intuitive but were unsupported and have shown that transplantation may greatly improve the lives of patients with HIV and ESRD. The next step is to develop effective treatments for all HIV-related kidney diseases before they progress to ESRD."

Investigator affiliations: University of California at San Francisco, San Francisco, CA; EMMES Corporation, Rockville, MD; Mount Sinai School of Medicine, New York, NY; Beth Israel Deaconess Medical Center, Boston, MA; University of Miami School of Medicine, Miami, FL; Washington Hospital Center, Washington, DC; Georgetown University, Washington, DC; University of Maryland, Baltimore, MD; Johns Hopkins University School of Medicine, Baltimore, MD; University of Pennsylvania, Philadelphia, PA; Drexel University College of Medicine, Philadelphia, PA; Rush University Medical Center, Chicago, IL; University of Chicago, Chicago, IL; Northwestern University, Chicago, IL; Emory University, Atlanta, GA; University of Virginia, Charlottesville, VA; Tulane Medical Center, New Orleans, LA; University of Pittsburgh, Pittsburgh, PA.

12/3/10

References

PG Stock, B Barin, B Murphy, M Roland, and others. Outcomes of kidney transplantation in HIV-infected recipients. New England Journal of Medicine 363(21): 2004-2014 (Abstract). November 18, 2010.

LA Szczech. Tackling the unknowns in HIV-related kidney diseases (Editorial). New England Journal of Medicine 363(21): 2058-2059. November 18, 2010.