South African doctors say they have safely carried out four kidney transplants from HIV-positive donors to patients with end-stage renal disease who have HIV infection, and that developing a donor pool of HIV-positive people would expand the number of people in resource-limited settings who could benefit from kidney transplants.
The findings, published today in the New England Journal of Medicine, come from doctors at Grote Schuur Hospital in Cape Town.
It is the first report from anywhere in the world on the safety of transplanting a kidney from an HIV-positive donor to another person with HIV infection. All other reports of kidney transplants in people with HIV concern transplants from HIV-negative donors.
The chief concern over kidney transplantation from one HIV-positive donor to another is the potential risk of superinfection with a strain or subtype of HIV that results in more rapid HIV disease progression in the transplant recipient.
The four cases reported all had end-stage renal disease, and had viral load suppressed below 50 copies on antiretroviral therapy. All had fairly low CD4 cell counts, ranging from 132 cells/mm3 to 288 cells/mm3. Three suffered from HIV-related nephropathy, while one patient had end-stage renal disease related to hypertension.
All organs came from two donors who had died of unspecified causes, and who had received no antiretroviral therapy. Neither had a history of opportunistic infections or cancer, and had no evidence of kidney disease on biopsy.
The patients, three men and one woman, received immunosuppressive therapy to prevent rejection of the donated organ, and after 12 months no cases of organ rejection had occurred. In all cases the transplant recipients enjoyed good renal function after the transplant, without the need for dialysis.
Although CD4 counts remained lower than baseline in three of the four patients 12 months after the transplant (due to the immunosuppressive therapy), all patients maintained a viral load below 50 copies, suggesting that any virus transplanted alongside the kidney had not affected control of HIV infection.
The authors say that more research is needed to assess whether viral characteristics like sub-type affect the risk of organ rejection or HIV disease progression, and suggest that use of a boosted protease inhibitor would increase the chances of suppressing any drug-resistant virus that is transplanted along with the kidney.
Three of the four transplant recipients received different antiretroviral regimens after the transplant, switching from NNRTI-based treatment to a regimen of lopinavir/ritonavir (Kaletra) plus tenofovir and 3TC.
“Transplantation programs in resource-limited settings cannot offer renal replacement to all patients who are in need. The use of HIV-infected donors would increase the donor pool,” say the authors.
They say that kidneys from deceased donors with HIV infection could be transplanted to other people with HIV if the kidney proved healthy at biopsy, providing that recipients have good adherence to antiretroviral treatment, undetectable viral load and evidence of immune reconstitution.
Muller E et al. Renal transplantation between HIV-positive donors and recipients. N Engl J Med 362 (24): 2336-37, 2010.