Survival is “excellent” among people living with HIV undergoing kidney transplants, according to a new analysis presented by researchers associated with the Solid Organ Transplantation in HIV Study at the 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention on Monday, July 18, in Rome. The study authors also note a clear survival advantage among people living with HIV undergoing liver transplants, but also made clear that certain pre-transplant risk factors—such as hepatitis C virus (HCV) coinfection, low body mass index and low Model for End-Stage Liver Disease (MELD) scores—may negative affect survival and increase the risk for serious post-surgery complications.
Historically, people with end-stage organ disease were excluded from organ transplant lists—lists that are tightly guarded to begin with—if they had HIV. This is because experts once believed that the organs should go to people with better chances of survival.
In the late 1990s, however—with the introduction of potent combination antiretroviral (ARV) therapy—survival for people living with HIV increased substantially, effectively ending arguments that they were less likely to live than their HIV-negative counterparts. And as end-organ disease continues to be a major cause of illness and death among people living with the virus, the need for organs—from both live and cadaveric donors—is high.
According to George Beatty, MD, MPH, of the University of California at San Francisco, and his colleagues, the limited experience with liver and kidney transplants since combination ARV therapy was introduced has been encouraging. Yet the optimal selection criteria—determining which people living with HIV will benefit most from transplants—and predictors of outcomes remain undefined.
Beatty's group set out to describe both rates and predictors of patient survival, AIDS-related opportunistic infections and cancers, and other serious infections requiring hospitalization among 125 HIV-positive liver transplant recipients and 150 HIV-positive kidney transplant recipients.
Kidney recipients were followed in the study for an average of 2.3 years; liver transplant recipients were followed for an average of 2.7 years.
One year after transplant surgery, 95 percent of the kidney recipients and 80 percent of the liver recipients were still alive. Three years after transplant surgery, survival rates were 91 and 67 percent, respectively.
The factors associated with death among kidney recipients were hepatitis C virus (HCV) coinfection and, to a lesser extent, age. The need for thymoglobulin—a drug used to treatment kidney transplant rejection—was also suggested to be a factor associated with death, but these finding was not statistically significant.
As for liver transplant recipients, factors shown to be associated with an increased risk of death during the follow-up period were dual-organ transplant—individuals who received both a kidney and liver, for example—a pre-transplant body mass index below 21, and receiving a liver from a donor older than 40. Factors that were marginally associated with mortality were HCV infection and a detectable HIV viral load before transplant surgery.
Beatty and his colleagues also reported that the clearest survival benefit after liver transplantation was among those with high MELD scores—those with the most advanced end-stage liver disease. For those with lower MELD scores, signaling less advanced end-stage liver disease, survival rates were no better compared to those in the study who were on waiting lists but had not had a transplant. Though AIDS-related opportunistic infections (OIs) and cancers were documented in patients both before and after transplant surgery, Beatty's group noted that there were no recurrences in patients with OI histories, despite the use of immune-suppressing drugs to prevent organ rejection. He also noted no survival differences based on OI history.
There were many serious infections that either required hospitalization or occurred while patients were hospitalized following transplant surgery, Beatty noted. About half the liver-transplant and kidney-transplant recipients required hospitalization for a variety of bacterial, fungal, viral and protozoal infections.
Factors associated with initial serious infection, among kidney recipients, were HCV coinfection, thymoglobulin use and lowest-ever CD4 count. Among liver recipients, HCV coinfection, the length of time the CD4 count remained compromised and white race were factors associated with initial serious infection.
In conclusion, Beatty noted, “Kidney survival is excellent, and liver transplant in high MELD confers survival.” As for pre-transplant factors to consider among people living with HIV, he noted that body mass index, HCV infection and the need for dual organ transplants—but nothing specific to HIV or its treatment—may influence recommendations regarding selection criteria in liver candidates.