Medical and Transplant Information

Are organs from HIV-infected donors viable to be transplanted into HIV-infected patients?

A surgical team in South Africa has reported results for at least 10 patients transplanted with kidneys from HIV-infected donors.[1] Outcomes, while preliminary, are excellent, with patients remaining virally suppressed with stable kidney function up to three years after transplantation.

In addition, in its recent Public Health Service Guidelines, the US Centers for Disease Control and Transmission (CDC) wrote that research on these types of transplants needs to be conducted, but noted that current law would need to be changed to allow for such transplants.[2]

Is it currently possible to conduct research in the transplantation of organs from HIV-infected donors to HIV-infected recipients without changing the law?

No. Only by repealing the current federal ban would it be possible to carefully study the safety and outcomes of these transplants in the same way that transplantation of HIV-infected recipients with uninfected donor organs has been carefully studied. Continued clinical and comparative-effectiveness research is required in this area once these procedures become a possibility for HIV-infected patients. Currently physicians in South Africa are doing this research, but the outdated ban makes such research currently impossible in the United States.

What has changed since the discovery of HIV/AIDS in the 1980s?

The understanding of HIV/AIDS and the medical community's ability to manage the condition have profoundly grown since HIV/AIDS was first discovered, representing perhaps one of the most impressive success stories in modern medicine.[6] What used to be a rapid death sentence has become a manageable chronic disease. Highly active antiretroviral therapy (HAART) has dramatically improved life expectancy and quality of life in HIV-infected patients. HIV-infected patients are living much longer, many with life expectancies mirroring those in the general population.

What are the applicable medical concerns among patients living with HIV?

Now that HIV-infected patients are living longer, other chronic conditions such as kidney and liver failure have emerged.[4, 5, 6] These are conditions for which organ transplant is the standard of care treatment. Many people with HIV experience high rates of serious co-morbidities including HIV-associated nephropathy (HIVAN), hepatitis C virus co-infection, and HAART toxicity which can cause kidney and liver failure. These diseases progress more rapidly in patients infected with HIV.[7, 8] Hepatitis C virus co-infection among people with HIV is as high as 30% and liver failure associated with hepatitis C virus is now a major cause of death among people living with HIV/AIDS. Kidney failure is also a major cause of morbidity and mortality among these patients.[9] In fact, in the United States, HIV-associated nephropathy is the third leading cause of kidney failure among African American men -- behind diabetes and high blood pressure.[10,11]

What safeguards will ensure HIV-infected organs are separate, and not mistakenly transplanted into uninfected patients?

To minimize the risk of inadvertently placing an HIV-infected organ into an uninfected recipient, the transplant community will draw on systems that have been put in place after years of transplanting organs from hepatitis C infected donors to hepatitis C infected recipients, as well as the robust, meticulous system for matching donors and recipients that is already in place.[12] The United Network for Organ Sharing (UNOS) / Organ Procurement and Transplantation Network (OPTN) (Health Resources and Services Administration (HRSA)/Health and Human Services (HHS)) has specific organ placement systems that only allow those patients that are medically able to accept an organ from a hepatitis C infected donor to appear on the list of possible recipients. There is very specific policy in place to ensure that in order to receive this opportunity of receiving the donated hepatitis C infected donor organ, the intended recipients name must appear on the list. This is verified several times throughout the process. In addition to these strict administrative processes, there are parallel robust safeguards in place at the level of the hospital and the surgeons. There has never been a case of an organ from a donor infected with hepatitis C accidentally allocated to an uninfected patient. A similar system utilized for HIV-infected patients would ensure that only HIV-infected patients would appear on this list, mirroring the experience with hepatitis C.

Can HIV-infected patients receive transplants if they are in kidney or liver failure?

HIV-infected patients are currently eligible to receive transplants from uninfected donors. Though in the early era of HIV/AIDS, HIV-infected patients were considered medically ineligible to receive transplants, medical advances have made transplantation for HIV-infected patients safe and feasible. In a recent national, multicenter, National Institutes of Health (NIH)-funded study, Dr. Peter Stock (UCSF Medical Center) and colleagues demonstrated that well-selected HIV-infected kidney transplant recipients can have organ and patient survival rates comparable to those in uninfected recipients.[9] This encouraging experience shows that transplant immunosuppression (the powerful drugs that transplant recipients take to prevent their bodies from rejecting organs) does not necessarily counteract the ability to suppress HIV with HAART.

What are the benefits of using organs from HIV-infected donors?

Using organs from donors infected with HIV for recipients infected with HIV will have a widespread, positive public health impact:

  1. Uninfected patients will be transplanted faster because HIV-infected patients can draw from a unique organ supply which is inappropriate for the majority of patients on the waitlist.
  2. HIV-infected patients will be transplanted faster. Some patients can wait as long as 7-10 years for their transplants, and many die waiting.[13] Drawing on parallel experiences with transplanting organs from hepatitis C infected donors to hepatitis C infected recipients, research has demonstrated that using organs from donors infected with hepatitis C for recipients with hepatitis C is a safe long-term strategy that is highly beneficial for many hepatitis C infected patients, significantly reducing waiting times (by 1-2 years or more) and risk of death on the waiting list.[14, 15] A similar advantage for HIV-infected patients who will accept HIV-infected organs can be expected, but this would only be possible if NOTA is revised.
  3. More HIV-infected patients will be referred for transplant. A recent study demonstrated that HIV-infected patients are listed for transplants at lower rates than their uninfected counterparts.[16] Since there are currently more HIV-infected organs available than there are HIV-infected patients listed for transplantation, better referral for HIV-infected patients should not cause further burden to the waiting list.

What are the risks of using organs from HIV-infected donors?

The true risks are unknown -- that is why research is needed in this area. The risk of superinfection (a new infection occurring in a patient having a preexisting infection) will need to be better understood. However, transplanting organs from stable, virally suppressed HIV-infected donors into stable, virally suppressed HIV-infected recipients is likely to be safe based on what is known about disease transmission risk in other settings.[17] In addition, the potential risks of such a procedure must be weighed against the great risk of the patient dying (10-20% per year) while on the waiting list for an uninfected organ.[18]

Would agreeing to accept an organ from an HIV-infected donor cause HIV-infected patients to "lose their place in line" for an organ from an uninfected donor on the regular waiting list?

No, HIV-infected patients who agree to accept organs from HIV-infected donors would not be bypassed and thus "lose their place in line" if they agree to accept an organ from a donor with the same infection. If an organ became available from an uninfected donor sooner than one from an HIV-infected donor, that patient would be offered the uninfected organ in the same manner as an uninfected patient (based on established criteria, i.e. waiting time, blood/tissue compatibility). By opting-in through informed consent to receive an organ from a donor with the same infection, HIV-infected patients would be increasing the likelihood that they would be transplanted faster because organs from HIV-infected donors are inappropriate for uninfected patients. A quicker road to transplantation benefits patients who are waiting because of the substantial risk of death on the waiting list.

Which organs can HIV-infected patients accept?

The majority of patients (>80%) on the transplant waiting list are waiting for kidneys, followed by livers. As major causes of morbidity and mortality in HIV-infected patients are kidney and liver failure, these trends follow for HIV-infected patients waiting for transplants as well. Cardiovascular disease has also emerged as a leading cause of death in HIV-infected patients. Consequently, HIV-infected patients have also successfully undergone heart and lung transplants with survival rates comparable to those in uninfected recipients.[19, 20]

Can organs from HIV-infected donors be transplanted to uninfected recipients?

The objective is to allow for transplants between HIV-infected donors and recipients. However, in the case of an extreme medical emergency, we envision that it should not be illegal to transplant an HIV-infected organ to an uninfected recipient. This is a complex situation which would require informed consent and input from the patient, his/her family, the physicians and an institutional ethics board. This is exactly how organs from donors infected with hepatitis C are allocated.


References

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  2. http://www.regulations.gov/#!docketDetail;dct=FR%252BPR%252BN%252BO%252BSR;rpp=10;po=0;D=CDC-2011-0011.
  3. Palella FJ, Jr., Baker RK, Moorman AC, et al. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study. J Acquir Immune Defic Syndr 2006;43:27-34.
  4. Fine DM, Perazella MA, Lucas GM, Atta MG. Renal disease in patients with HIV infection: epidemiology, pathogenesis and management. Drugs 2008;68:963-80.
  5. Weber R, Sabin CA, Friis-Moller N, et al. Liver-related deaths in persons infected with the human immunodeficiency virus: the D:A:D study. Arch Intern Med 2006;166:1632-41.
  6. Mocroft Aa, Kirk Ob, Gatell Jc, et al. Chronic renal failure among HIV-1-infected patients. AIDS 2007;21:1119-27.
  7. Sherman KE, Rouster SD, Chung RT, Rajicic N. Hepatitis C Virus prevalence among patients infected with Human Immunodeficiency Virus: a cross-sectional analysis of the US adult AIDS Clinical Trials Group. Clin Infect Dis 2002;34:831-7.
  8. Thomas DL. Hepatitis C and human immunodeficiency virus infection. Hepatology 2002;36:S201-9.
  9. Stock PG, Barin B, Murphy B, et al. Outcomes of kidney transplantation in HIV-infected recipients. N Engl J Med 2010;363:2004-14.
  10. Lucas GM, Lau B, Atta MG, Fine DM, Keruly J, Moore RD. Chronic kidney disease incidence, and progression to end-stage renal disease, in HIV-infected individuals: a tale of two races. J Infect Dis 2008;197:1548-57.
  11. Choi AI, Rodriguez RA, Bacchetti P, Bertenthal D, Volberding PA, O'Hare AM. Racial Differences in End-Stage Renal Disease Rates in HIV Infection versus Diabetes. J Am Soc Nephrol 2007;18:2968-74.
  12. Ali MK, Light JA, Barhyte DY, et al. Donor hepatitis C virus status does not adversely affect short-term outcomes in HCV+ recipients in renal transplantation. Transplantation 1998;66:1694-7.
  13. Margaret VR, Bijan E, Kimberly WS, Igor D, John JF. Pretransplant survival is shorter in HIV-positive than HIV-negative subjects with end-stage liver disease. Liver Transplantation 2005;11:1425-30.
  14. Mandal AK, Kraus ES, Samaniego M, et al. Shorter waiting times for hepatitis C virus seropositive recipients of cadaveric renal allografts from hepatitis C virus seropositive donors. Clinical Transplantation 2000;14:391.
  15. Northup PG, Argo CK, Nguyen DT, et al. Liver allografts from hepatitis C positive donors can offer good outcomes in hepatitis C positive recipients: a US National Transplant Registry analysis. Transplant International.
  16. Sawinski D, Wyatt CM, Casagrande L, et al. Factors associated with failure to list HIV-positive kidney transplant candidates. Am J Transplant 2009;9:1467-71.
  17. Shen L, Siliciano RF. Viral reservoirs, residual viremia, and the potential of highly active antiretroviral therapy to eradicate HIV infection. J Allergy Clin Immunol 2008;122:22-8.
  18. Port FK, Wolfe RA, Mauger EA, Berling DP, Jiang K. Comparison of survival probabilities for dialysis patients vs cadaveric renal transplant recipients. JAMA 1993;270:1339-43.
  19. Castel MA, Perez-Villa F, Miro JM. Heart transplantation in HIV-infected patients: more cases in Europe. J Heart Lung Transplant 2011;30:1418.
  20. Bertani A, Grossi P, Vitulo P, et al. Successful lung transplantation in an HIV- and HBV-positive patient with cystic fibrosis. Am J Transplant 2009;9:2190-6.