HIV-Infected Kidney Graft Recipients Managed With an Early Corticosteroid Withdrawal Protocol

Abstract

Background The outcome of HIV-infected kidney transplant recipients managed with an early corticosteroid withdrawal protocol is not known. Methods Eleven consecutive HIV-infected patients with undetectable plasma HIV RNA and >200/mm3 CD4+ T-cells underwent deceased (n=8) or living donor (n=3) kidney transplantation at our center. All were managed with an early corticosteroid withdrawal protocol; 9 of 11 received anti-thymocyte globulin and 2 received basiliximab induction. We analyzed patient and graft outcomes, acute rejection (AR) rate, HIV progression, BKV replication, infections and urinary cell mRNA profiles. Results The median follow-up was 44.5 months (range: 26-73). The incidence of AR was 9% at one year and patient and allograft survival rates were 100% and 91%, respectively. Estimated glomerular filtration rate at one year (mean ± SD) was 78±39 ml/min/1.73m2. Plasma HIV RNA was undetectable at 24 months and none had BKV replication. Six of the 11 kidney recipients developed eight infections requiring hospitalization. Urinary cell levels of mRNA for complement components and complement regulatory proteins, cell lineage specific proteins CD3, CD4, CD8, CTLA4, Foxp3, chemokine IP-10, cytotoxic perforin and granzyme B and BKV–VP1 mRNA were not different (P>0.05) between HIV-infected patients and HIV-negative recipients (n=22) with stable graft function and normal biopsy results. Conclusion An early steroid withdrawal regimen with anti-thymocyte globulin induction was associated with excellent graft and patient outcomes in HIV-infected recipients of kidney allografts. Their urinary cell mRNA profiles are indistinguishable from those of HIV negative patients with stable graft function and normal biopsy results.

Renal transplantation in human immunodeficiency virus‐infected recipients: a case–control study from the Brazilian experience

“…The same pattern of immunosuppressive treatment has been observed in other studies. In all recent studies, CNIs were largely utilized, and interestingly, some reports have suggested that adequate immunosuppression, without maintenance steroids, may be possible in HIV-infected recipients (11,(24)(25)(26)(27).…”

Current status of kidney transplantation in HIV-infected patients

“…In contrast to most of the above studies in which steroids were incorporated into the treatment regimen, Muthukumar et al [15] have recently reported the use of a 'steroid-free' approach in 11 HIVþ recipients under induction with rabbit antithymocyte globulin followed by tacrolimus-mycophenolate mofetil maintenance therapy. One-year patient survival was 100% and by 3 years it was 90%.…”

Kidney transplantation in HIV-positive patients treated with a steroid-free immunosuppressive regimen

“…In agreement with a recent report by Muthukumar et al . , only one case of NODAT was observed in recipients on steroid‐free regimen. In addition, the only episode of acute myocardial infarction observed in our population occurred in a patient taking steroids.…”

“…Muthukumar et al . recently reported a very low rate of AR in HIV+ kidney graft recipients with early corticosteroid withdrawal who underwent induction therapy with thymoglobulin. The incidence of infections observed with this approach did not differ from that reported in HIV‐negative recipients treated with lymphocyte‐depleting antibodies .…”