title: Immunosuppression regimen and the risk of acute rejection in HIV-infected kidney transplant recipients.
abstract: BACKGROUND
  Kidney transplantation (KT) is the treatment for end-stage renal disease in appropriate HIV-positive individuals. However, acute rejection (AR) rates are over twice those of HIV-negative recipients.
  
  
  METHODS
  To better understand optimal immunosuppression for HIV-positive KT recipients, we studied associations between immunosuppression regimen, AR at 1 year, and survival in 516 HIV-positive and 93,027 HIV-negative adult kidney-only recipients using Scientific Registry of Transplant Recipients data from 2003 to 2011.
  
  
  RESULTS
  Consistent with previous reports, HIV-positive patients had twofold higher risk of AR (adjusted relative risk [aRR], 1.77; 95% confidence interval [CI], 1.45-2.2; P<0.001) than their HIV-negative counterparts as well as a higher risk of graft loss (adjusted hazard ratio, 1.51; 95% CI, 1.18-1.94; P=0.001), but these differences were not seen among patients receiving antithymocyte globulin (ATG) induction (aRR for AR, 1.16; 95% CI, 0.41-3.35, P=0.77; adjusted hazard ratio for graft loss, 1.54; 95% CI, 0.73-3.25; P=0.26). Furthermore, HIV-positive patients receiving ATG induction had a 2.6-fold lower risk of AR (aRR, 0.39; 95% CI, 0.18-0.87; P=0.02) than those receiving no antibody induction. Conversely, HIV-positive patients receiving sirolimus-based therapy had a 2.2-fold higher risk of AR (aRR, 2.15; 95% CI, 1.20-3.86; P=0.01) than those receiving calcineurin inhibitor-based regimens.
  
  
  CONCLUSIONS
  These findings support a role for ATG induction, and caution against the use of sirolimus-based maintenance therapy, in HIV-positive individuals undergoing KT.
authors.affiliation: 1 Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL. 2 Division of Transplantation, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD. 3 Division of Transplant Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL. 4 Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL. 5 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. 6 Address correspondence to: Jayme E. Locke, M.D., M.P.H., Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, 701 19th Street South, LHRB 748, Birmingham, AL 35294.
authors.forename: Jayme E
authors.initials: JE
authors.lastname: Locke
authors.forename: Nathan T
authors.initials: NT
authors.lastname: James
authors.forename: Roslyn B
authors.initials: RB
authors.lastname: Mannon
authors.forename: Shikha G
authors.initials: SG
authors.lastname: Mehta
authors.forename: Peter G
authors.initials: PG
authors.lastname: Pappas
authors.forename: John W
authors.initials: JW
authors.lastname: Baddley
authors.forename: Niraj M
authors.initials: NM
authors.lastname: Desai
authors.forename: Robert A
authors.initials: RA
authors.lastname: Montgomery
authors.forename: Dorry L
authors.initials: DL
authors.lastname: Segev
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000961:Antilymphocyte Serum / Q000378:metabolism; D065095:Calcineurin Inhibitors; D005260:Female; D006084:Graft Rejection; D006085:Graft Survival; D015658:HIV Infections / Q000150:complications* / Q000276:immunology; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods*; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D007676:Kidney Failure, Chronic / Q000150:complications / Q000628:therapy*; D016030:Kidney Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012042:Registries; D012306:Risk; D020123:Sirolimus / Q000737:chemistry; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000961:Antilymphocyte Serum; D065095:Calcineurin Inhibitors; D007166:Immunosuppressive Agents; D020123:Sirolimus