5-Year Survival High for HIV+ to HIV+ Kidney Transplant

Veronica Hackethal, MD

October 04, 2019

HIV positive individuals have high rates of 5-year overall survival and kidney graft survival after receiving a transplant from a deceased donor with HIV, according to new research conducted in South Africa and published October 3 in the New England Journal of Medicine.

The study adds much-needed evidence about long-term clinical outcomes for people with HIV who receive kidney transplants from HIV-positive donors, with no evidence of transmitted drug resistance or superinfection, say Philippe Selhorst, PhD, University of Cape Town, South Africa, and colleagues, including some from the US National Institutes of Allergy and Infectious Disease (NIAID).

"In South Africa, the United States, and elsewhere, a growing number of people with HIV have a need for kidney transplants. Unfortunately, these gifts of life are too often in short supply," said Anthony S. Fauci, MD, director of NIAID, in a press release from his institution.

"This observational study provides additional evidence that organs from donors with HIV could be a new donation source for people living with both HIV and end-stage renal disease," he said.

"If these findings are corroborated in ongoing clinical trials, we will have a chance to improve the health of many people living with HIV and increase the overall supply of transplantable organs," he added.

HIV Positive Individuals at Increased Risk of Renal Damage

People with HIV are at increased risk for end-stage renal disease because of renal damage caused by the HIV virus itself as well as the medication needed to treat it. And other infections that often occur along with HIV, such as hepatitis B and C, as well as comorbidities such as high blood pressure and diabetes, may also harm the kidneys. 

Until recently, people with HIV were rarely eligible to receive organ transplants from HIV-negative donors because health outcomes were projected to be poor, and it is still rare in South Africa that such transplants are performed, say the researchers.

And HIV-positive to HIV-positive kidney transplants were illegal in the United States until the HIV Organ Policy Equity (HOPE) Act was passed in 2013. The act allows organ transplants from HIV-positive donors to HIV-positive recipients with end-stage organ failure, provided an approved research protocol is in place.

Past research from the NIAID laid the groundwork for this legislation by suggesting similar survival rates for kidney or liver transplants from HIV-negative individuals to those living with HIV and organ failure (but otherwise healthy) compared with recipients without HIV.

A goal of the legislation was to shorten the wait time for transplantable kidneys available to HIV-positive individuals.

Tracking the Situation in South Africa

To evaluate longer-term outcomes for HIV-positive to HIV-positive kidney transplants, Selhorst and coauthors followed all 51 HIV-positive individuals in South Africa who received kidney transplants from deceased HIV positive donors after 2011.

All recipients were virally suppressed when they received their transplant, and most continued on the same antiretroviral therapy (ART).

One year after transplant, patient survival was high at 87% and remained so at 3 years and 5 years (83.3%).

Likewise, kidney graft survival was high: 96% at 1 year, 93% at 3 years, dropping a little to 79% at 5 years.

The authors note that these percentages are similar to 3-year overall survival (88.2%) and 3-year graft survival (73.7%) from a previous US study that examined HIV-negative donor to HIV-positive recipient kidney transplant (N Engl J Med. 2010;363:2004-2014).

The percentages of patients who did not have graft rejection were 75% at 1 year, 61% at 3 years, and 56% at 5 years.

No Sign of Resistance, Superinfection

Researchers also analyzed blood samples from 15 donors and 26 recipients.

Results showed drug-resistant mutations in the HIV virus in six recipients, but none came from donors. Virus from the donor was detected in the blood samples of eight recipients (32%), but none needed to change their ART regimen because of failure to suppress the virus. No recipients showed increased viral load or new viral resistance.

Researchers also tested for viral superinfection. They found one possible case, which appeared to be transient, and which they believe may have been residual virus from the donor, not true superinfection. They plan to continue monitoring all participants for superinfection.

"The favorable clinical outcomes and the absence of transmitted drug resistance, as well as the absence of evidence for sustained donor-derived superinfection, support the use of HIV positive to HIV positive renal transplantation as a treatment option," they conclude.

Coauthor Andrew D. Redd, PhD, also of the NIAID, said: "Taken together with the positive long-term clinical outcomes we found in our study, we feel our data strongly support the expanded use of these life-saving transplantations."

NIAID is funding two ongoing large clinical trials in the United States that are comparing clinical outcomes for HIV-positive donor to HIV-positive recipient versus HIV-negative donor to HIV-positive recipient organ transplants: the HOPE in Action Multicenter Kidney Study (begun in 2018) and HOPE in Action Multicenter Liver Study (begun in February 2019).

The study was supported by the United States–South Africa Program for Collaborative Biomedical Research from the South African Medical Research Council (MRC), National Institutes of Health (NIH), and Division of Intramural Research, NIAID. Selhorst has reported receiving grants and personal fees from the Poliomyelitis Research Foundation, as well as grants and personal fees from the Centre for the Aids Programme of Research in South Africa (CAPRISA) Centre of Excellence. One or more authors have reported receiving consulting fees and/or grants from the UK National Institute for Health Research. The other authors have reported no relevant financial relationships.

N Engl J Med. 2019;381:1387-1389. Abstract

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