Safety and success of kidney transplantation and concomitant immunosuppression in HIV-positive patients.
BACKGROUND
Human immunodeficiency virus-associated nephropathy (HIVAN) has become the third leading cause of end-stage renal disease (ESRD) in African Americans, and is expected to grow exponentially. Highly active antiretroviral therapy (HAART) has significantly prolonged the survival of patients with HIV infection. Despite the growing number of HIV-positive dialysis patients with prolonged life expectancy, kidney transplantation with immunosuppression has been declined because it is considered a waste of scarce donor kidneys due to potential increases in morbidity and mortality.


METHODS
The institutional review board of Drexel University College of Medicine and Hahnemann University Hospital approved this prospective study. The aim was to find out safety and success of kidney transplantation, and the effect of immunosuppression on HIV infection. Forty HIV-positive dialysis patients received kidney transplantation between February 2001 and January 2004. Patient inclusion criteria were maintenance of HAART, plasma HIV-1 RNA of <400 copies/mL, absolute CD4 counts of 200 cells/muL or more. Immunosuppression was basiliximab induction and maintenance with cyclosporine, sirolimus, and steroids. HAART was continued post-transplant. Acute rejections were diagnosed by biopsy and treated with methylprednisolone. Surveillance biopsies were completed at 1, 6, 12, and 24 months, and evaluated for subclinical acute rejection, chronic allograft nephropathy, and HIVAN.


RESULTS
One- and 2-year actuarial patient survival was 85% and 82%, respectively, and graft survival was 75% and 71%, respectively. Plasma HIV-1 RNA remained undetectable, and CD4 counts remained in excess of 400 cells per muL with no evidence of AIDS for up to 2 years.


CONCLUSIONS
One- and 2-year graft survival is comparable to other high-risk populations receiving kidney transplantation. One- and 2-year patient survival is higher than HIV patients maintained on dialysis. Immunosuppression does not adversely affect HIV recipients maintained on HAART in the short term.
Kumar
Mysore S Anil
MS
Department of Surgery/Transplantation, Drexel University College of Medicine and Hahnemann University Hospital, Philadelphia, PA 19102, USA. ak59@drexel.edu
Sierka
Debra R
DR
Damask
Anna M
AM
Fyfe
Billie
B
McAlack
Robert F
RF
Heifets
Michael
M
Moritz
Michael J
MJ
Alvarez
Daniel
D
Kumar
Aparna
A
D016263:AIDS-Associated Nephropathy / Q000601:surgery*; D002180:Candidiasis, Oral / Q000517:prevention & control; D003622:Dapsone / Q000627:therapeutic use; D005260:Female; D006084:Graft Rejection / Q000276:immunology; D006679:HIV Seropositivity / Q000150:complications / Q000276:immunology; D006801:Humans; D007676:Kidney Failure, Chronic / Q000209:etiology / Q000601:surgery; D016030:Kidney Transplantation / Q000276:immunology / Q000379:methods* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D009761:Nystatin / Q000627:therapeutic use; D016720:Pneumocystis Infections / Q000517:prevention & control; D012189:Retrospective Studies; D012449:Safety; D012842:Sarcoma Virus, Woolly Monkey; D016019:Survival Analysis; D016896:Treatment Outcome
D009761:Nystatin; D003622:Dapsone