HIV+ Patients Get Good Outcomes After Kidney or Liver Transplant
Liver or kidney transplant recipients who are HIV-positive show outcomes that are similar to those without HIV at 15-years post-transplant, in new research that represents some of the longest follow-up on these patients to date.
The findings further support the inclusion of people with HIV in transplant resource allocation, say the researchers.
“Overall, the excellent outcomes following liver and kidney transplant recipients in HIV-infected recipients justify the utilization of a scarce resource,” senior author Peter G. Stock, MD, PhD, surgical director of the Kidney and Pancreas Transplant Program and surgical director of the Pediatric Renal Transplant Program at the University of California San Francisco (UCSF), told Medscape Medical News.
“Many centers still view HIV as a strict contraindication [for transplantation]. This data shows it is not,” he emphasized.
The study, published this week in JAMA Surgery, involved HIV-positive patients who received kidney or liver transplants between 2000 and 2019 at UCSF, which has unique access to some of the longest-term data on those outcomes.
“UCSF was the first US center to do transplants routinely in people with HIV, and based on the large volume of transplants that are performed, we were able to use propensity matching to address the comparison of HIV-positive and negative liver and kidney transplant recipients at a single center,” Stock explained.
“To the best of our knowledge, there are no long-term reports [greater than 10 years] on [transplant] outcomes in the HIV-positive population.”
Commenting on the study, David Klassen, MD, chief medical officer of the United Network for Organ Sharing (UNOS), noted that the findings “confirm previous research done at UCSF and reported in the New England Journal of Medicine,” in 2010, he told Medscape. “It extends the previous findings.”
“The take-home message is that these HIV-positive patients can be successfully transplanted with expected good outcomes and will derive substantial benefit from transplantation,” Klassen said.
Kidney Transplant Patient Survival Lower, Graft Survival Similar
For the kidney transplant analysis, 119 HIV-positive recipients were propensity matched with 655 recipients who were HIV-negative, with the patients’ mean age about 52 and approximately 70% male.
At 15-years post-transplant, patient survival was 53.6% among the HIV-positive patients vs 79.6% for HIV-negative (P = .03).
Graft survival among the kidney transplant patients was proportionally higher among HIV-positive patients after 15 years (75% vs 57%); however, the difference was not statistically significant (P = .77).
First author Arya Zarinsefat, MD, of the Department of Surgery at UCSF, speculated that the lower long-term patient survival among HIV-positive kidney transplant recipients may reflect known cardiovascular risks among those patients.
“We postulated that part of this may be due to the fact that HIV-positive patients certainly have additional comorbidities, specifically cardiovascular” ones, he told Medscape.
“When looking at the survival curve, survival was nearly identical at 5 years, and only started to diverge at 10 years post-transplant,” he noted.
A further evaluation of patients with HIV who were co-infected with hepatitis C (HCV) showed that those with HIV-HCV co-infection prior to the center’s introduction of anti-HCV direct-acting antiviral (DAA) medications in 2014 had the lowest survival rate of all subgroups, at 57.1% at 5 years post-transplant
(P =.045 vs those treated after 2014).
Liver Transplant Patient Survival Similar
In terms of liver transplant outcomes, among 83 HIV-positive recipients who were propensity-matched with 468 HIV-negative recipients, the mean age was about 53 and about 66% were male.
The patient survival rates at 15 years were not significantly different between the groups, at 70% for HIV-positive and 75.7% for HIV-negative, (P = .12).
Similar to the kidney transplant recipients, the worst survival among all liver transplant subgroups was among HIV-HCV co-infected patients prior to access to HCV direct-acting antivirals in 2014, with a 5-year survival of 59.5% (P = .04).
“Since the advent of HCV direct-acting antivirals, liver transplant outcomes in HCV mono-infected patients are comparable to HCV/HIV co-infected recipients,” Stock said.
Acute Rejection Rates Higher with HIV-Positivity vs National Averages
The rates of acute rejection at 1 year in the kidney and liver transplant, HIV-positive groups — at about 20% and 30%, respectively — were, however, higher than national average incidence rates of about 10% at 1 year.
Long-term data on those patients showed the acute rejection affected graft survival outcomes with kidney transplant recipients: HIV-positive kidney transplant recipients who had at least one episode of acute rejection had a graft survival of just 52.8% at 15 years post-transplant, compared with 91.8% among recipients without acute rejection.
Such differences were not observed among HIV-positive liver transplant recipients.
The authors note that the increased risk of acute rejection in HIV-positive kidney transplant patients is consistent with previous studies, with causes that may be multifactorial.
Top theories include drug interactions with protease inhibitors, resulting in some centers transitioning HIV-infected patients from those regimens to integrase-based regimens prior to transplant.
“The management and prevention of acute rejection in HIV-positive kidney transplant [patients] will therefore continue to be a key component in the care of these patients,” the authors note in their study.
The study was supported in part by the National Institutes of Health. The study authors and Klassen have disclosed no relevant financial relationships.
JAMA Surgery. Published online January 5, 2022. Abstract
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