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Transplantation in HIV: Survival and Disease Progression Study

This study aims to evaluate the effect of immunosuppression on survival and HIV disease progression in HIV-infected patients who undergo transplantation. The study also investigates the impact of HIV on graft survival and any potential drug interactions. Results show comparable patient survival and graft survival rates to national data. HIV disease progression is not significant in selected patients, with stable CD4+ T-cell counts and suppressed HIV-1 RNA levels. However, there have been opportunistic infections and rejection cases.

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Transplantation in HIV: Survival and Disease Progression Study

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  1. Transplantation in HIV Michelle Roland, MD Assistant Professor of Medicine UCSF Positive Health Program at SFGH

  2. Background • HIV-infected patients have been excluded from consideration for transplantation because: 1. Morbidity too high to justify organ use 2. 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

  3. 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

  4. 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 Counts Kidney: 455 (200 - 1054) Liver: 321 (103 - 973) • Baseline HIV-1 RNA Liver: <50 (<50 - 115,776)

  5. 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

  6. Results: Outcomes • CD4+ T Cell Counts Kidney 460 (76 - 1300) Liver 296 (89 - 590) • HIV-1 RNA Kidney < 50 (< 50 - 11,343) Liver <50 (<50 - 80) • Re-transplantation 1 liver • Graft loss 1 kidney • Additional rejection 36% kidney + 11% liver

  7. 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

  8. Conclusions • Patient survival is comparable to UNOS data at 1 year 95% 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 year 89% kidney subjects UNOS = 89.4% cadaver/94.5% living 84% liver subjects UNOS = 81.4%

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