Kidney Transplant in a Human Immunodeficiency Virus-Positive Patient: Case Report of Drug Interactions

Abstract

End-stage renal disease in the human immunodeficiency virus-positive population is increasing. Kidney transplant is the optimal therapy for this population rather than dialysis modalities if some criteria are met. These include undetectable plasma human immunodeficiency virus RNA, CD4 cell count over 200 cells/µL, and the absence of any AIDS-defining illness. Here, we describe the first living-donor kidney transplant in a human immunodeficiency virus-positive recipient in Turkey. The patient, a 52-year-old male diagnosed as human immunodeficiency virus positive, was on antiretroviral therapy, which consisted of 400 mg twice daily darunavir, 100 mg/day ritonavir, and 50 mg/day dolutegravir. He had been negative for human immunodeficiency virus RNA for the past 3 years. The patient developed renal insufficiency without any known cause and started hemodialysis. A living donor transplant from his son was performed, and the patient received ATG Fresenius-S (Neovii Biotech, Rapperswil, Switzerland) induction and a maintenance immunosuppression therapy consisting of methylprednisolone, mycophenolate mofetil, and tacrolimus. There were no incidences of delayed graft function or acute rejection. Because of tacrolimus and ritonavir interaction, tacrolimus trough levels were too high. With tacrolimus withdrawn, tacrolimus trough level decreased to detectable levels 2 weeks later. Antiretroviral therapy was continued on the same dosage. At month 4 posttransplant, the patient's creatinine level was 1.01 mg/dL. At present, the patient has had no complications and no episodes of rejection. Kidney transplant is the most favorable replacement therapy for HIV-positive patients who are under controlled AIDS care with highly active antiretroviral therapy. However, drug interactions should be carefully evaluated. Key words: HIV infection, Immunosuppression, Renal transplantation IntroductionThe introduction of highly active antiretroviral therapy has reduced the mortality and progression to acquired immunodeficiency syndrome (AIDS). However, end-stage renal disease can occur in patients who are human immunodeficiency virus (HIV) positive. A broad spectrum of diseases such as hypertension, diabetes mellitus, and glomerular diseases are the major causes of end-stage kidney disease. 1 Human immunodeficiency virus-associated nephropathy is a specific glomerular collapsing sclerosing disease seen in HIV-positive patients. 2 Whatever the cause, renal transplant is the optimal therapy for the HIV-positive population rather than dialysis modalities if some criteria are met. These criteria include undetectable plasma HIV RNA, CD4 cell count over 200 cells/μL, and the absence of any AIDS-defining illnesses. 3 Over time, the best immunosuppression modalities have become better known for this population of patients. However, drug interactions are still important points with immunosuppression therapy. Delayed graft function (DGF) and acute rejection are the most important issues to be noted carefully during the early posttransplant perio...

Dolutegravir-Based Antiretroviral Regimens for HIV Liver Transplant Patients in Real-Life Settings

“…Patients 6 and 10 experienced increased serum creatinine concentrations (from 1.3 to 1.8 mg/dL and from minimal dependence on CYP3A-mediated metabolism, high potency and high genetic barrier [3,4]. However, data on the use of dolutegravir in real-life transplant settings are limited and exclusively involve kidney transplant recipients [5][6][7][8][9]. Here, we sought to describe the use of dolutegravir-based maintenance ART in HIV-positive liver transplant patients regularly followed in our hospital.…”

Important Interactions of Immunosuppressants With Experimental Therapies for Novel Coronavirus Disease (COVID-19): How to Act

“…2 Similar increases in exposure were confirmed in transplant patients with hepatitis C and human immunodeficiency virus. 3,4 Sirolimus and everolimus concentrations are also expected to increase when used in combination with ritonavir, but no concise data are available. Interaction of sirolimus and everolimus with the strong CYP3A inhibitor ketoconazole led to 10-and 15-fold increases in exposure, respectively.…”