Reconsideration of Hiv as a Contraindication to Transplantation

The historical exclusion from transplantation of human immunodeficiency virus (HIV) infected patients was based on the logical premise that immunosuppression required for organ transplantation would exacerbate an immunocompromised state. However, the prognosis for people with HIV infection has dramatically improved with the clinical use of highly active anti-retroviral therapy (HAART). Clinical trials of antiretroviral (ARV) agents have demonstrated significant virologic, immunologic, and survival benefits associated with the use of protease inhibitor (PI) or nonnucleoside reverse transcriptase inhibitor (NNRTI) containing regimens, when combined with two nucleoside analogues. The incidence of opportunistic infections and hospitalizations has decreased with the use of HAART. In combination with historical data, suggesting that a subpopulation of HIV+ transplant recipients tolerate immunosuppression and have allograft survival comparable to that of HIV− transplant recipients, these results indicate that the medical community should readdress HIV infection as an absolute contraindication to transplantation. Certainly, outcome data is lacking regarding liver and/or kidney transplantation in HIV+ patients in the era of HAART. In a recent attempt to query the transplant community regarding this issue, a survey was distributed by the Scientific Studies Committee of the American Society of Transplant Surgeons to its membership with the promise of anonymity. A total of 814 surveys were distributed in October 1999 with 179 respondents (22%). Within the 5 years preceding the survey (1994–1999), a total of 8 transplants (2 kidney and 6 liver) were performed in HIV+ patients. The length of follow-up varied from 3 years to 6 months; patient survival was 75% (6/8) with 2 deaths among the liver recipients resulting from JC virus and VRE sepsis. Uniformly, inclusion criteria included a CD4+ cell count greater than 200 and the presence of an undetectable HIV viral load. Immunosuppression was either cyclosporine- or tacrolimus-based; all recipients remained on HAART after the transplant. (Since completion of the survey, an additional four kidney transplants have been performed with subsequent normal graft function—Paul C. Kuo, M.D. and Peter J. Stock, M.D., Ph.D., personal communications) Although anecdotal and by no means complete, these data suggest that transplant centers are embarking upon kidney and liver transplantation in select groups of HIV+ patients. People with HIV infection have been traditionally excluded from consideration for solid organ transplantation out of concern about the potential adverse effects of immunosuppressive drugs on HIV progression in a disease characterized by progressive immunocompromise. However, recent medical advances, such as HAART, have improved outcomes in HIV disease and as a result, there is now an increase in death from end-stage organ disease rather than AIDS-associated opportunistic infections and neoplasms. In light of the dramatic improvement in the treatment and survival of people with HIV, the transplant and HIV communities should re-evaluate the policy of HIV as a contraindication to organ transplantation. Although many questions about HIV and transplantation remain unanswered, enough data exists to warrant reconsideration of HIV disease in transplantation.