Transplantation in HIV

Michelle Roland, MD

Assistant Professor of Medicine

UCSF Positive Health Program at SFGH

Background

• HIV-infected patients have been excluded from consideration for transplantation because:1. Morbidity too high to justify organ use2. Immunosuppression might accelerate HIV disease

• Mortality is reduced with HAART

• Prospective study will evaluate:1. Effect of immunosuppression on survival and HIV disease

2. Effect of HIV on graft survival

3. Drug interactions between PI/NNRTI and immunosuppressives

• Many centers transplanted patients prior to the study

Methods

• Prospective analysis of enrolled subjects +• Retrospective review of recipients at study centers

• “Eligible” subjects: • No opportunistic infection history• CD4 > 200 kidney; >100 liver• HIV RNA < 50 kidney, liver or unable to tolerate ARVs in liver

but post-transplant suppression predicted

• “Ineligible” subjects:• Did not meet 1 or more criteria above

Results: Baseline• 41 “Eligible” Subjects

• 22 Kidney and 19 Liver

• 8 “Ineligible” Subjects• undiagnosed HIV, HIV RNA > 50 (K), low

CD4, altered MS, history of OI/ON

• Baseline CD4+ T Cell CountsKidney: 455 (200 - 1054)Liver: 321 (103 - 973)

• Baseline HIV-1 RNALiver: <50 (<50 - 115,776)

Results: Outcomes

• Median follow-up 279 days (3 - 1567)

• Deaths 1 kidney + 3 liver

- recurrent hepatitis C

- rejection after PI stopped

- post-op complications x 2

• Opportunistic Complications

1 liver + 1 kidney

- CMV esophagitis

- candida esophagitis

Results: Outcomes

• CD4+ T Cell CountsKidney 460 (76 - 1300)Liver 296 (89 - 590)

• HIV-1 RNAKidney < 50 (< 50 - 11,343)

Liver <50 (<50 - 80)

• Re-transplantation 1 liver• Graft loss 1 kidney• Additional rejection 36% kidney + 11% liver

Outcomes: Ineligible Subjects

• Undiagnosed HIV death (MAC< PML)

• Altered MS death (PML)

• HIV RNA > 50 (K) all <50 or < 400

• Low CD4 stable 76 --> 102

• History of OI/ON

(PCP + CMV; KS + CMV) no recurrence at

15 months and 5

weeks

Conclusions

• Patient survival is comparable to UNOS data at 1 year95% kidney subjects UNOS = 94.8% cadaver/97.6% living

84% liver subjects UNOS = 87.9%

• No significant HIV disease progression in selected pts• 2 OI s could be due to HIV or immunosuppression• Stable CD4+ T-cell counts and suppressed HIV-1 RNA

• There is HIV progression with advanced disease

• Graft survival is comparable to UNOS data at 1 year89% kidney subjects UNOS = 89.4% cadaver/94.5% living

84% liver subjects UNOS = 81.4%