Kidney and liver transplantation in human immunodeficiency virus-infected patients: a pilot safety and efficacy study.
BACKGROUND
Human immunodeficiency virus (HIV)-infected patients have historically been excluded from consideration for transplantation out of concern for the effects of immunosuppression on the progression of HIV disease. Improvements in HIV-related morbidity and mortality with the use of highly active antiretroviral therapy (HAART) have prompted a reevaluation of transplantation as a treatment option for HIV-infected patients with end-stage kidney and liver disease.


METHODS
Eligible patients met standard transplant criteria. They had undetectable plasma HIV-1 RNA levels (viral load) for 3 months (kidney) or were predicted to achieve viral load suppression posttransplantation if unable to tolerate HAART (liver); a CD4+ T-cell count of more than 200 cells/microL (kidney) or more than 100 cells/microL (liver) for 6 months; and no history of opportunistic infections and neoplasm. Standard immunosuppression included prednisone, mycophenolate mofetil (CellCept, Roche Pharmaceuticals, Basel, Switzerland), and cyclosporine (Neoral, Novartis, East Hanover, NJ).


RESULTS
Fourteen patients received transplants (10 kidney transplants, mean follow-up 480 days; four liver transplants, mean follow-up 380 days). All of the kidney transplant recipients (100%) are alive and with functioning grafts, and three of four liver transplant patients (75%) are alive and well with functioning grafts (all liver transplant patients with normal liver function tests). The one death occurred 445 days posttransplantation in a liver recipient coinfected with hepatitis C virus, who died as the result of its rapid reoccurrence. Rejection occurred in 5 of 10 kidney transplant recipients but did not occur in any of the four liver transplant recipients. HIV viral loads have remained undetectable in all patients maintained with HAART. CD4 counts have remained stable in patients not treated for rejection. Patients receiving protease inhibitors require 25% of the dose of cyclosporine compared with patients receiving nonnucleoside reverse transcriptase inhibitors.


CONCLUSIONS
There has been no evidence of significant HIV progression and no adverse effect of HIV on allograft function. Rejection is a concern in kidney transplant recipients, as is the possible poor outcome in hepatitis C virus-coinfected liver transplant recipients. Preliminary data are encouraging and indicate that transplantation should be a treatment option for individuals with well-controlled HIV disease.
Stock
Peter G
PG
Department of Surgery, Division of Transplantation, University of California, San Francisco, California 94143-0780, USA. stockp@surgery.ucsf.edu.
Roland
Michelle E
ME
Carlson
Laurie
L
Freise
Chris E
CE
Roberts
John P
JP
Hirose
Ryutaro
R
Terrault
Norah A
NA
Frassetto
Lynda A
LA
Palefsky
Joel M
JM
Tomlanovich
Stephen J
SJ
Ascher
Nancy L
NL
D000328:Adult; D019380:Anti-HIV Agents / Q000493:pharmacokinetics; D023241:Antiretroviral Therapy, Highly Active; D000075202:Contraindications; D004347:Drug Interactions; D005260:Female; D006085:Graft Survival; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality*; D006801:Humans; D007165:Immunosuppression Therapy; D007166:Immunosuppressive Agents / Q000493:pharmacokinetics; D007676:Kidney Failure, Chronic / Q000150:complications / Q000601:surgery* / Q000821:virology; D016030:Kidney Transplantation; D017093:Liver Failure / Q000150:complications / Q000601:surgery* / Q000821:virology; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects
D019380:Anti-HIV Agents; D007166:Immunosuppressive Agents