Is HIV infection a contraindication for kidney transplantation?

Kathrin Hochegger, Gert J. Mayer and Alexander R. Rosenkranz

Leopold-Franzens Universität Innsbruck Klinische Abteilung fuer Nephrologie Innsbruck Tyrol Austria Email: alexander.rosenkranz{at}uibk.ac.at

Sir,

We read with great interest the recently published article by Zeier and Ritz [1] concerning the preparation of the dialysis patients for transplantation. Interestingly, the authors stated that patients with human immunodeficiency virus (HIV) infections are currently excluded from renal transplantation programs. Since we have been confronted with the request of kidney transplantation in an HIV-positive dialysis patient at our institution, we performed a literature research and contacted several transplant centres worldwide on this issue.

Between 1993 and 1997, ~1% of dialysis patients in the USA were diagnosed with HIV-associated nephropathy (HIV-AN), and 2–5% of the dialysis patients are HIV positive [2]. HIV-AN is expected to be one of the leading causes of ESRD in black men in the new millenium. In HIV-positive Caucasians, immune complex glomerulopathy is the most prevalent finding in those with proteinuria and haematuria [3]. In the era before antiretroviral therapy, the median survival in the HIV-infected population on dialysis was ~10 months [4]. The improvements in the survival of patients infected with HIV associated with the use of highly active antiretroviral therapy (HAART) and advances in the prevention of opportunistic infections has resulted in a life expectancy of 10–20 years [5,6]. Therefore, an increasing number of HIV-infected patients are dying from ESRD rather than AIDS-associated opportunistic infections and neoplasms. In a recent retrospective study of 22 HIV-positive dialysis patients, a significant decrease in mortality and an increase in survival has been described in the HAART group compared with single or dual antiretroviral therapy [7].

The published renal transplant experience is quite promising, with the largest retrospective review demonstrating six of 11 renal allografts functioning at a mean follow-up of 31 months. During the same follow-up period, 27% of the patients progressed to AIDS with no evidence of HIV-related opportunistic diseases in the remaining patients [8]. More than 1 year ago, the first prospective trial was started by Peter Stock and colleagues from the University of California, which will include 75 HIV-positive ESRD patients. Preliminary results from this trial have recently been published as an abstract at the American Transplant Congress 2002 [9]. Selection criteria include compliance to HAART therapy and dialysis, plasma HIV 1 RNA of <50 copies/ml, CD4 count of >200/ml and absence of overt HIV disease. So far, 12 patients have been included with a graft survival of 100% after 6 and 12 months post-transplant, respectively. Thirty-three percent of the recipients had an acute rejection episode that was successfully treated in all of the patients. All of the recipients have a functioning graft with serum creatinine levels between 1.1 and 2.3 mg/dl. The most challenging part comprises the immunosuppression regimen due to interactions with HAART therapy. Nevertheless, the authors stated that the outcome of renal transplantation in HIV patients is comparable to HIV-negative recipients at 1 year, and therefore, HIV-positive status should not preclude transplantation in select patients. In the light of the new data and the upcoming prospective trial, HIV positivity as an absolute contraindication for renal transplantation should be reconsidered.

References

  1. Zeier M, Ritz E. Preparation of the dialysis patient for transplantation. Nephrol Dial Transplant2002; 17:552–556[Free Full Text]
  2. US Renal Data System. 1999 Annual Data Report. Am J Kidney Dis1999; 34:S40–S50[ISI]
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  6. Detels R, Munoz A, McFarlane G et al. Effectiveness of potent antiretroviral therapy on time to AIDS and death in men with known HIV infection duration. J Am Med Assoc1998; 280:1497–1503[Abstract/Free Full Text]
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  8. Ahuja T, Zingman B, Glicklich D. Long-term survival in an HIV-infected renal transplant recipient. Am J Nephrol1997; 17:480–482[ISI][Medline]
  9. Kumar AM, Damask A, Roland M et al. Kidney transplantation in HIVG positive end stage renal disease patients—a prospective study. Am J Transplant2002; 2:174