Organ transplantation for HIV-positive patients

Not long ago, organ transplantation was not considered an option for HIV infected patients.

However, in recent years, new clinical approaches have led to good outcomes in the growing number of HIV-positive patients who need kidney and liver transplants. Recent developments in organ transplantation for patients with HIV are summarized in the September 15, 2007, issue of Transplantation, the official journal of The Transplantation Society and published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health, leading global provider of healthcare content, context and consulting.

"The blanket exclusion of HIV infected patients can no longer be justified based on the early results demonstrating the safety and efficacy of transplantation in this group of patients," write Drs. Peter G. Stock and Michelle E. Roland of University of California, San Francisco, (UCSF) in the September issue of the Transplantation journal.

Modern treatments—especially the anti-HIV drug combinations known as highly active antiretroviral therapy (HAART)—have greatly decreased the risk of death from AIDS and other causes in patients with HIV. However, as they live longer, patients are at risk of other HIV-related complications, including kidney and liver disease related to hepatitis B and C infection. The HAART drugs can also have toxic effects on the liver, compounding the damage caused by hepatitis.

Drs. Stock and Roland cite progress in several key areas—including the ability to control HIV infection using HAART and improved measures to prevent opportunistic infections—that have made organ transplantation an increasingly viable option for HIV-positive patients. Studies performed in the "post-HAART" era at UCSF and elsewhere have shown promising results. In one study of liver transplantation in HIV-positive patients, the 3-year survival rate was 73 percent—similar to that of HIV-negative patients.

At transplant centers worldwide, criteria for considering transplantation in HIV-positive patients are "slowly being liberalized," according to the authors. In most cases, patients must have "undetectable" HIV levels before kidney transplantation can be considered. Exceptions may be made for patients with liver damage related to HAART drugs.

At first it was thought that, because of their weakened immune systems, HIV-positive patients would need less immunosuppressant therapy to prevent transplant rejection. However, early experience has suggested that rejection rates may be higher in HIV-positive patients, especially early after kidney transplantation. There is also evidence that some of the immunosuppressant drugs given after transplantation also have antiretroviral (anti-HIV) effects.

More research will be needed to understand the complex interactions between HAART and immunosuppressant drugs, and to develop specific immunosuppressant strategies for HIV-positive patients. So far, there is no evidence that the risk of progression to AIDS is increased after organ transplantation.

Further progress is needed in these and other key areas. Meanwhile, the concept of organ transplantation for HIV-positive patients is increasingly accepted by insurers and policymakers in the United States and elsewhere. "It is imperative that HIV-positive patients, HIV health care providers, and the transplant community are aware that transplant is a viable option for the HIV infected patient," Drs. Stock and Roland conclude.

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