Renal Tx Improves HIV Patients' Survival

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Transplantation significantly increased five-year survival rate compared with remaining on dialysis.

TORONTO—HIV-infected individuals with end-stage renal disease (ESRD) have significantly better odds of survival if they have a kidney transplant than if they remain on dialysis, according to recently released data.

The study, conducted at Drexel University in Philadelphia, examined the outcomes of 159 HIV-

positive individuals on highly active antiretroviral therapy. Eighty-six patients remained on dialysis and 73 received transplants, with 67 of the latter receiving deceased-donor kidneys and six receiving live-donor kidneys.

The dialysis and transplant groups were similar in average age, ethnicity (with 90% and 92%, respectively, being African American), causes of renal failure, and comorbidities, researchers said.

The five-year survival rate was 85% for transplant recipients compared with 27.5% for those remaining on dialysis. The rates of graft survival echoed these patterns, the researchers reported at the 2008 American Transplant Congress.

The graft survival rates in HIV-positive patients were lower than those among HIV-negative transplant recipients at the same institution, said lead investigator Mysore Anil Kumar, MD, professor of surgery at Drexel and chief of the Division of Transplantation at Hahnemann University Hospital in Philadelphia.

“The reason for this is that HIV-positive patients are taking medications to control HIV infection [and these] are toxic to the kidney, causing higher rejection rates,” Dr. Kumar explained.

“We do not treat rejection in HIV patients with the same potent drugs as in non-HIV patients, for fear of [aggravating the] HIV infection. If it comes to a point of choosing between saving the kidney and aggravation of the HIV infection, which could be fatal, we stop treating the kidney and let the patient go back to dialysis.”

Dr. Kumar and his colleagues concluded that transplantation should be offered to all HIV-positive pa-tients with ESRD provided they do not have contraindications.

The findings of the new study are in line with a study by Peter Stock, MD, and colleagues published earlier this year in the American Journal of Transplantation (2008;8:355-365) demonstrating a 94% three-year survival among 18 HIV-positive kidney transplant recipients.

“I agree that these patients should be transplanted,” Dr. Stock told Renal & Urology News. “The question I have is, with the patients who didn't get transplanted, why didn't they? Was it because they looked too sick? We don't know what the transplant recipients' long-term function will be because the investigators didn't present the results on creatinine clearance.” Dr. Stock, who is professor of surgery at the University of California, San Francisco, is leading an NIH-sponsored study of the outcomes of HIV-positive kidney transplant recipients. It includes UCSF, Drexel, and other institutions.

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