February 25, 2009

HIV and Organ Transplants Can Coexist, UCSF Research Shows

By Robin Hindery

Huge progress has been made in recent years in the fight against HIV/AIDS, improving quality of life for people infected with the virus, but also presenting a new set of health challenges as those individuals live longer than their 20th century counterparts.

Kidney disease and liver disease now pose two of the greatest threats to HIV-infected individuals, and until recently, the chances of these patients receiving new organs were slim.

But thanks to groundbreaking work by UCSF researchers, that is no longer the case, and medical institutions across the country are jumping on board to help dispel the myth that HIV is an impenetrable barrier to a successful transplant.

“Increasingly, people are aware that HIV isn’t the contraindication [to transplantation] that it was before,” said Laurie Carlson, RN, a UCSF transplant research coordinator and the author of a recent paper in the Nephrology Nursing Journal making the case for kidney transplants for HIV-infected patients. “I really think UCSF has moved this agenda forward. It truly is a big thing, and a lot has been accomplished not just clinically, but politically, policywise and advocacywise.”

UCSF’s work began in 2000, when the University of California’s systemwide AIDS Research Program awarded $1 million to a research team led by UCSF physicians Peter Stock, MD, and Michelle Roland, MD, to conduct the first pilot study of liver and kidney transplantation in patients with HIV. From 2000 to 2003, the study monitored the one- and three-year survival rates of 29 patients who underwent either kidney or liver transplants.

The team found that after one year, 91 percent of liver transplant patients were still alive, and after three years, 81 percent were still alive. Among kidney transplant patients, the survival rate was even higher: 94 percent both one year and three years after surgery.

Those results were promising, even when compared with survival rates among the HIV-negative population, Stock said, and he and his team proceeded to expand their study to include 20 other transplant centers around the country. The UCSF-sponsored observational study funded by the National Institutes of Health and other sources has enrolled about 250 participants so far, and Stock said he expects to reach the target of 275 patients by the end of the year.

The study is addressing some increasingly pressing questions among the medical and patient advocacy communities as kidney and liver disease affect more and more people with HIV.

Every year, approximately 800 new patients starting dialysis in the United States cite HIV-associated kidney disease as the cause of their renal failure, according to the US Renal Data System. In addition, studies have shown that roughly 40 percent of HIV-infected individuals in the United States are also infected with either hepatitis C or hepatitis B, liver diseases that can lead to organ failure.

Those troubling figures are the unfortunate result of a far more positive trend. Thanks to highly effective antiretroviral therapy, the average life expectancy among HIV-infected individuals increased 13 years between 1996 and 2005, according to a study published in 2008 by researchers at the British Columbia Centre for Excellence in HIV/AIDS.

“It’s the downside to progress,” Carlson said. “Now people live long enough to develop chronic illnesses on top of the ones they’re already dealing with.”

The UCSF researchers’ findings have helped chip away at medical myths surrounding transplants for individuals with HIV, but Carlson cautions that not all HIV-infected patients are good candidates for a transplant.

“The best candidates are patients who have well-controlled HIV disease, higher CD4 [white blood cell] counts and who can handle their medications,” she said. “We want to be sure we can manage the HIV and not accelerate its progression by performing a transplant.”

One finding that took researchers by surprise was the high organ rejection rate among HIV-infected patients undergoing kidney transplants. Stock said he and his colleagues expected that the patients’ already weakened immune systems wouldn’t put up much of a fight when a new organ was introduced, but “we were very wrong.”

This problem may be caused, in part, by the way HIV-positive patients metabolize the immunosuppressant drugs that are meant to prevent organ rejection, Stock said. But he acknowledged that there may be additional factors at play.

“We’re still trying to get a handle on that and it’s something we have to fix,” he said.

Carlson said she hoped UCSF’s ongoing research and her recent paper, which ran in the November-December 2008 issue of the Nephrology Nursing Journal, would help educate doctors and nurses with HIV-positive patients.

“We’re moving from a study phase to more of a clinical care phase, and I thought it was time to share some of our promising results and experience here [at UCSF] and give some guidelines to other folks,” she said.

UCSF celebrated its 45th year of transplantation in 2008 and continues to boast the world’s largest kidney transplant program with more than 10,000 transplants performed since 1964.

Clinical Management of the HIV-Positive Kidney Transplant Recipient

Laurie Carlson
Nephrology Nursing Journal (November-December 2008) 35(6):559-567
Full Text (PDF)

Clinical Management of the HIV-Positive Kidney Transplant Recipient

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