Risk of End-Stage Renal Disease in HIV-Positive Potential Live Kidney Donors

Abstract

New federal regulations allow HIV-positive individuals to be live kidney donors; however, potential candidacy for donation is poorly understood given the increased risk of end-stage renal disease (ESRD) associated with HIV. To better understand this risk, we compared the incidence of ESRD among 41,968 HIV-positive participants of NA-ACCORD followed for a median of 5 years with the incidence of ESRD among comparable HIV-negative participants of NHANES-III followed for a median of 14 years. We used risk associations from multivariable Cox proportional hazards regression to derive cumulative incidence estimates for selected HIV-positive scenarios (no history of diabetes, hypertension, AIDS, or HCV co-infection) and compared these estimates with those from similarly selected HIV-negative scenarios. For 40-year-old HIV-positive individuals with health characteristics that were similar to those of age-matched kidney donors, viral load <400 copies/mL, and CD4+ count ≥500 cells/μL, the 9-year cumulative incidence of ESRD was higher than their HIV-negative peers, yet still low: 2.5 versus 1.1 per 10,000 among white females, 3.0 versus 1.3 per 10,000 among white males, 13.2 versus 3.6 per 10,000 among black females, and 15.8 versus 4.4 per 10,000 among black males. HIV-positive individuals with no comorbidities and well-controlled disease may be considered low-risk kidney donor candidates.

Knowledge, attitudes, and planned practice of HIV‐positive to HIV‐positive transplantation in US transplant centers

“…However, our study found that most centers (83.2%) support HIV D+/R+ living donation. This perception is supported by a recent study demonstrating that HIV+ individuals with well‐controlled HIV have a similar risk of ESRD as their HIV‐uninfected counterparts . Furthermore, recent studies have found that people living with HIV are willing to be living organ donors …”

In sickness and in health: Living HIV positive kidney donation from a wife to her husband, with 7 years' post‐transplant follow‐up

“…Another key point in this case is the issue of short‐ and long‐term complications post‐donation for HIV‐infected living kidney donor. The data from North America AIDS Collaboration on Research and Design (NA‐ACORD) indicate that peak HIV viral load is a risk factor for ESRD; while rates of ESRD among HIV + individuals have decreased with ART, they are not zero and the residual risk still exists . Our donor had the highest documented viral load of 13 175 copies/mL at the time of diagnosis, and it dropped to undetectable soon after ART initiation, so no additional data of her possible previous exposure to potentially higher levels of viremia were available.…”

“…The increased risk for ESRD among HIV‐positive individuals with well‐controlled HIV infection meeting the standard kidney donor eligibility criteria is real. However, this added risk is still not high, theoretically enabling relatively low‐risk live kidney donation …”

Current state of kidney transplantation in patients with HIV, hepatitis C, and hepatitis B infection

“…To date, only two HIV+ individuals have served as living kidney donors in the United States. Although projections estimate that the risk of ESKD among people living with HIV who could be living kidney donors is acceptable, 49 the true risk is unknown; thus many transplant centers are reluctant to consider HIV+ living donor candidates at this time.…”