Kidney Transplantation in HIV-positive Patients: Current Practice and Management Strategies

Abstract

The spectrum of renal pathology in HIV-positive individuals is diverse, including lesions directly related to intrarenal HIV gene expression and lesions related to comorbidities, ReviewBackground. HIV-positive patients had been successfully transplanted for the last 15 y and the donor pool had successfully been expanded to also include HIV-positive donors. Methods. We aimed to evaluate the effectiveness of transplantation in HIV-positive patients and highlight some of the important issues reported in the literature. We pooled clinical data from different cohorts to show some of the common issues encountered in HIV-positive transplantation. Furthermore, we searched MEDLINE via PubMed, EMBASE, Cochrane CENTRAL to create a comprehensive table for current evidence for different issues currently encountered when transplanting HIV-positive patients. Results. We included data from 19 cohort studies and reported on outcomes of the current HIV-positive transplant programs. We made recommendations based on personal experience as well as the experience reported in the literature regarding rejection, opportunistic infection, and HIV-associated nephropathy. Opportunistic infections and malignancies are not a major problem for this population group. Conclusions. HIV-positive patients encounter very specific issues after transplantation, specifically related to drug interactions and higher rejection rates. When utilizing HIV-positive donors, the recurrence of HIV-associated nephropathy in the graft kidney is an issue which can be important. Despite some issues with high rejection rates, HIV-positive patients have similar results to HIV-negative patients posttransplantation.

Importance of multidisciplinary collaboration for smooth kidney transplantation in HIV-infected patients with chronic kidney disease: a case report

“…According to overseas data, the graft survival rate of HIV-infected kidney transplant recipients after ART is 90.4% and 73.7% at 1 and 3 years, respectively, with survival rates of 94.6 and 88.2% at 1 and 3 years, respectively [9]. These data are similar to the prognosis for HIV-negative kidney transplant patients [2]; however, we could not find data for Japan. Acute kidney injury associated with HIV includes the direct nephrotoxicity of indinavir and tenofovir used for ART [10].…”

“…HIV is a single-stranded RNA virus that infects CD4positive T lymphocytes, and opportunistic infections are likely to occur when CD4-positive T lymphocytes fall below 200/μL. Before introducing antiretroviral therapy (ART), the prognosis of patients who developed AIDS was extremely poor; ART has dramatically improved the prognosis of Japanese patients [1,2].…”

“…The risk of end-stage kidney failure in HIV-positive patients is approximately four times that in HIV-negative patients, and the risk of kidney dysfunction is also high [5]. Although ART has improved the prognosis of HIVpositive dialysis patients and kidney transplant recipients [2,6], discrimination and prejudice persist in HIV care in Japan, and medical personnel are uncomfortable providing care for patients with HIV. Against this background, kidney transplantation in HIV-infected patients with CKD in Japan is underreported.…”

Retrospective Review of ART Regimens in HIV-Positive to HIV-Positive Kidney Transplant Recipients

“…Possible reasons could include an altered immune response, the effect of the viral reservoir in the transplanted kidney, and drug interactions between immunosuppressive treatments and ART. 22 Recent evidence indicates that PIs may influence graft survival in HIV-positive renal transplant recipients. Sawinski et al 7 reported a 1.8-fold and 1.9-fold increased risk of graft loss and death respectively in 332 HIV-positive kidney transplant recipients in the Scientific Registry of Transplant Recipients database.…”

It is not only extending donor criteria: it is extending the donor pool. A cross‐sectional survey from the European Society of Organ Transplantation

“…In summary, many transplant professionals were willing to accept donors with an additional risk of transmission of infectious or malignant disease although there was no consensus on clinical pathways [1][2][3]. Many centres closed during the height of the pandemic and now have continuation plans in place [4][5][6].…”