Human immunodeficiency virus (HIV) is no longer a contraindication to transplantation, contends Dorry Segev, MD, PhD (American Journal of Transplantation 2011;11:1209-1217).
The Associate Professor of Surgery and Epidemiology and Director of Clinical Research at Johns Hopkins Comprehensive Transplant Center in Baltimore tells Renal & Urology News that kidney transplantation is a particularly strong contender for consideration in this matter.
How has the medical community in general reacted to the concept of using HIV-infected organs for HIV-positive recipients?
Dr. Segev: In general, there has been strong support for this effort. With Peter Stock’s outstanding results from the [National Institutes of Health] trial of transplantation in HIV-positive recipients (with HIV-negative organs), and Elmi Muller’s experience of HIV-to-HIV transplants in South Africa, the time is right for the US to be doing these kinds of transplants.
What feedback, if any, have you gotten specifically regarding HIV-infected-kidney transplantation?
Dr. Segev: The only experience of HIV-to-HIV has been in kidney transplantation (South Africa). Also, the outcomes of kidney transplantation in HIV-positive individuals (using HIV-negative organs) has been outstanding. So the support for HIV-to-HIV is actually strongest for kidney transplants.
Has the research outlined/defined a threshold of health for HIV-positive kidney donors and/or HIV-positive recipients that is best met to make this exchange significantly more beneficial than no such exchange?
Dr. Segev: Based on recent research, we know something about which HIV-infected recipients are appropriate for transplantation. There is evidence that HIV-infected recipients who are virally suppressed with good CD4 levels on stable [highly active antiretroviral therapy, or] HAART regimens are the ideal candidates for transplantation, and will have very few manifestations of their HIV disease in the setting of the transplant.
However, since transplanting HIV-infected organs is currently illegal, there has been no research (or even anecdotal experience) in the U.S. to inform what are appropriate or inappropriate HIV-infected donors. Some HIV experts believe that an organ from a virally suppressed potential donor, transplanted into a recipient on HAART [highly active antiretroviral therapy], would carry with it the least risk of superinfection.
What is the greatest medical issue(s) of contention preventing the widespread adoption of HIV-infected-organ transplantation for HIV-positive candidates?
Dr. Segev: People worry about the following:
A. Superinfection in the recipient—in other words, it is possible that someone had a virally suppressed strain of HIV and now becomes infected with a much more aggressive strain.
B. Safety considerations—in other words, there is fear that an organ from an HIV-infected donor might accidentally be allocated to, or accidentally transplanted into, an HIV-negative recipient.
How do you answer these concerns?
Dr. Segev: Superinfection is certainly a possibility, and we will have to learn how to best select donors to minimize this. In the South African experience, this has not yet become a demonstrable concern. Additionally, we must remember that the other option for HIV-infected patients is to wait on the deceased-donor waiting list for an HIV-negative organ.
The difference in waiting times might be between 3-8 years; in those 3-8 years, the risk is very high that the HIV-infected patient will die before receiving an HIV-negative organ offer. So even if there is some small risk of the HIV disease worsening, it is the renal disease that puts these patients at high risk of death, and transplantation decreases this risk.
Safety is always a consideration in solid-organ transplantation, and we have many mechanisms in place for ensuring that the correct organ is allocated to and transplanted into the correct recipient, including blood-type checks, cross-matches, etc. In particular, the case of hepatitis C is an important analogue.
Every year we recover hundreds of organs from donors infected with hepatitis C, and safeguards are in place to ensure that these organs are allocated to and transplanted into only recipients with hepatitis C infection. To my knowledge, there has never been an occurrence of accidental transmission of hepatitis C from a donor who was known to be infected into a recipient who was uninfected. These same safeguards could (and would) be used in HIV-positive donors.
What is the greatest ethical issue(s) of contention?
Dr. Segev: Nothing really ethical that I can think of. Some might say that we can’t be doing this as “standard practice” yet but rather that we need to do this only through research protocols.
How do you answer these concerns?
Dr. Segev: The law currently forbids any transplantation at all. Medical care should not be dictated in a congressional law. We need to reverse the law and make it legal to perform these transplants. Then we need to carefully develop [Organ Procurement and Transplantation Network] policies to make this as safe and medically wise as possible.
Considering how advances in HIV treatment have put HIV infection in the category of chronic disease—whereas a person in need of a kidney transplant is in a much more dire situation—what would be your reaction if nephrologists and/or their HIV-negative end-stage renal disease patients began to look into HIV-positive-donor organ transplantation?
Dr. Segev: It is unclear what will happen to a recipient who becomes acutely infected with HIV at the time of induction immunosuppression. This may be less benign than what occurs in a patient with stable, HAART-controlled HIV.
However, this certainly does occur with hepatitis C (some older adults would prefer hepatitis C to dialysis, because of its generally long latent period before symptoms arise) and might similarly occur with HIV. With HIV there might even be hope that peri-transplant HAART could minimize infection or aggressiveness of new infection. However, at this moment, we are probably not medically ready to handle this.