Kidney Transplantation from HIV-Positive Donors to HIV-Positive Recipients

Summary and Comment |
February 11, 2015

Kidney Transplantation from HIV-Positive Donors to HIV-Positive Recipients

  1. Sonia Nagy Chimienti, MD

Transplantation from select donors to carefully chosen recipients appears to be feasible and safe.

  1. Sonia Nagy Chimienti, MD

Kidney transplantation may be life saving for HIV-infected patients with chronic kidney disease who live in resource-poor settings, where renal-replacement therapy is a limited resource. Results from transplantation of HIV-negative donor kidneys into HIV-positive recipients have been encouraging. Now, researchers in South Africa (with partial industry funding) have evaluated outcomes of kidney transplantation from deceased HIV-positive donors to 27 HIV-positive recipients.

Donors either had never received antiretroviral therapy or had been on first-line therapy with virologic suppression at time of death; recipients were virologically suppressed, with CD4 counts >200 cells/mm3. All recipients received induction therapy with antithymocyte globulin; maintenance immunosuppression therapy with prednisone, tacrolimus, and mycophenolate mofetil; and prophylaxis for opportunistic infections (OIs) with trimethoprim-sulfamethoxazole and isoniazid, to be continued for life, and valganciclovir for 3 months.

Patient survival at 1 and 5 years was 84% and 74%, respectively; graft survival was 93% and 84%. (The graft was categorized as functioning at the time of death in 5 patients who died from nonrenal causes.) Outcomes were comparable to those of HIV-negative recipients in the same unit (patient survival of 91% and 85%, and graft survival of 88% and 75%, at 1 and 5 years, respectively). Rejection rates were high (8% at 1 year and 22% at 3 years), with two episodes leading to graft failure; one graft was removed at 2 weeks posttransplant because of severe antibody-mediated rejection. In all patients, virologic suppression was maintained through follow-up; CD4-cell counts declined during the first year, presumably due to the effects of antithymocyte globulin, but gradually recovered to baseline levels during follow-up. Three patients developed biopsy-proven HIV-associated nephropathy (HIVAN) in the allograft, a finding not seen on baseline biopsy.

Comment

Donors and recipients were carefully chosen to minimize the chances of transmitting drug-resistant HIV and the risk for reactivating OIs. Additional data are needed to compare rates of infections, malignancies, and HIVAN in renal allografts between recipients of kidneys from HIV-positive and HIV-negative donors, and to determine transmission rates of drug-resistant HIV from HIV-positive donors. The relatively high rejection rates noted in this and previous studies of HIV-positive transplant recipients require ongoing evaluation. Despite these concerns, kidney transplantation from select HIV-positive donors to carefully chosen HIV-positive recipients appears to be feasible and safe.

Editor Disclosures at Time of Publication

  • Disclosures for Sonia Nagy Chimienti, MD at time of publication Nothing to disclose

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