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Kidney transplantation may be life saving for HIV-infected patients with chronic kidney disease who live in resource-poor settings, where renal-replacement therapy is a limited resource. Results from transplantation of HIV-negative donor kidneys into HIV-positive recipients have been encouraging. Now, researchers in South Africa (with partial industry funding) have evaluated outcomes of kidney transplantation from deceased HIV-positive donors to 27 HIV-positive recipients.
Donors either had never received antiretroviral therapy or had been on first-line therapy with virologic suppression at time of death; recipients were virologically suppressed, with CD4 counts >200 cells/mm 3 . All recipients received induction therapy with antithymocyte globulin; maintenance immunosuppression therapy with prednisone, tacrolimus, and mycophenolate mofetil; and prophylaxis for opportunistic infections (OIs) with trimethoprim-sulfamethoxazole and isoniazid, to be continued for life, and valganciclovir for 3 months.
Patient survival at 1 and 5 years was 84% and 74%, respectively; graft survival was 93% and 84%. (The graft was categorized as functioning at the time of death in 5 patients who died from nonrenal causes.) Outcomes were comparable to those of HIV-negative recipients in the same unit (patient survival of 91% and 85%, and graft survival of 88% and 75%, at 1 and 5 years, respectively). Rejection rates were high (8% at 1 year and 22% at 3 years), with two episodes leading to graft failure; one graft was removed at 2 weeks posttransplant because of severe antibody-mediated rejection. In all patients, virologic suppression was maintained through follow-up; CD4-cell counts declined during the first year, presumably due to the effects of antithymocyte globulin, but gradually recovered to baseline levels during follow-up. Three patients developed biopsy-proven HIV-associated nephropathy (HIVAN) in the allograft, a finding not seen on baseline biopsy.
Muller E et al. HIV-positive–to–HIV-positive kidney transplantation — results at 3 to 5 years. N Engl J Med 2015 Feb 12 ; 372 : 610 . ( http://dx.doi.org/10.1056/NEJMoa1408896 )
Comment
Donors and recipients were carefully chosen to minimize the chances of transmitting drug-resistant HIV and the risk for reactivating OIs. Additional data are needed to compare rates of infections, malignancies, and HIVAN in renal allografts between recipients of kidneys from HIV-positive and HIV-negative donors, and to determine transmission rates of drug-resistant HIV from HIV-positive donors. The relatively high rejection rates noted in this and previous studies of HIV-positive transplant recipients require ongoing evaluation. Despite these concerns, kidney transplantation from select HIV-positive donors to carefully chosen HIV-positive recipients appears to be feasible and safe.