A 39 year old man with advanced HIV disease is alive and well two years after receiving a heart transplant, in a case reported in the June 2003 edition of the New England Journal of medicine. The patient, Dr Robert Zackin, a Harvard researcher is doing so well that he has returned to work and is one of the co-authors of the case report.
A comment accompanying the article notes the successful liver and kidney transplants conducted on HIV-positive patients, and suggests that with recent advances in both HIV and transplant medicine, the question should no longer be “why?” should a person with HIV be considered a candidate for organ transplant, but “why not?”
Dr Zackin was diagnosed with HIV in 1992, at which time he had the AIDS-defining pneumonia PCP and a CD4 cell count of 20 cells/mm3. His condition deteriorated further, with the diagnosis of MAI and KS, which was treated with liposomal daunorubicin and later paclitaxwl. Antiretrovirals were prescribed from 1992, with Dr Zackin starting a protease inhibitor based HAART regimen in 1995. After this his CD4 cell count rose to over 250 cells/mm3 and his viral load fell to below 50 copies/mL.
However, cardiomyopathy developed, probably as a consequence of anti-KS therapy, and by January 2001 Dr Kackin’s heart problems were life-threatening. Given his excellent response to HAART he was accepted as a donor candidate and in February 2001 underwent a successful heart transplant.
Dr Zackin’s cardiac function improved markedly after transplant, and this improvement has lasted through 24 months of follow-up. Although there has been no new AIDS-defining illness, Dr Zackin’s CD4 cell count has occasionally dipped 100 cells/mm3, as a concequence of immunosuppressive drugs given to prevent organ rejection. However there have been frequent episodes of organ rejection, and other complications including gouty arthritis have developed. In addition, Dr Zackin is transfusion-dependent. Nevertheless, his HIV viral load has remained undetectable and he has been able to return to work and exercise regularly.
The inclusion of ritonavir in his HAART regimen has necessitated careful dose adjustment of the anti-rejection drug cyclosporine.
Dr Zachin’s co-authors note in his case report that there are compelling scientific and ethical arguments for organ transplants to be considered in HIV-positive patients, concluding, “if HIV-infected patients are now expected to live long and productive lives when they are successfully treated, then they should not be penalized for the advances in medicine that may allow them to benefit from transplantation. The argument that such organs would be ‘wasted’ would only be supported if transplantation is demonstrably less successful in HIV-infected patients than other recipients. So far kidney and liver transplantations do not appear to be less successful in this population.” The investigators call for the publishing of other case reports.
A perspective accompanying Dr Zackin’s case report argues that HIV-positive patients with a good HIV prognosis have as good a short-term prognosis as other transplant recipients. However, careful monitoring is needed for potential interactions between anti-HIV drugs and drugs used to prevent organ rejection. The authors of the perspective also emphasise the need for skilled multidisciplinay teams. They conclude: “this case report…in conjunction with preliminary results from current studies of liver and kidney transplantation, provides hope that selected patients with HIV infection and end-organ failure can benefit from solid-organ transplantation.”
Further information on this website
Daunorubicin - overview
Organ transplants successful in people with HIV, but concerns about drug interactions - news story, September 2002
The heart - factsheet
Calabrese LH et al. Successful cardiac transplantation in an HIV-1-infected patient with advanced disease. New England Journal of Medicine 348: 2323 – 2328, 2003.
Roland ME et al. Responding to organ failure in HIV-infected patients New England Journal of Medicine 348: 2279 – 2281, 2003.