Thymoglobulin-Associated Cd4+ T-Cell Depletion and Infection Risk in HIV-Infected Renal Transplant Recipients

Abstract

HIV-infected patients are increasingly referred for kidney transplantation, and may be at an increased risk for rejection. Treatment for rejection frequently includes thymoglobulin. We studied thymoglobulin's effect on CD4+ T-cell count, risk of infection and rejection reversal in 20 consecutive HIV-infected kidney recipients. All patients used antiretroviral therapy and opportunistic infection prophylaxis. Maintenance immunosuppression consisted of prednisone, mycophenolate mofetil and cyclosporine. Eleven patients received thymoglobulin (7 for rejection and 4 for delayed/slow graft function) while 9 did not. These two groups were similar in age, gender, race, donor characteristics and immunosuppression. Mean CD4+ T-cell counts remained stable in patients who did not receive thymoglobulin, but became profoundly suppressed in those who did, decreasing from 475 ± 192 to 9 ± 10 cells/lL (p < 0.001). Recovery time ranged from 3 weeks to 2 years despite effective HIV suppression. Although opportunistic infections were successfully suppressed, low CD4+ T-cell count was associated with increased risk of serious infections requiring hospitalization. Rejection reversed in 6 of 7 patients receiving thymoglobulin. We conclude that thymoglobulin reverses acute rejection in HIV-infected kidney recipients, but produces profound and long-lasting suppression of the CD4+ T-cell count associated with increased risk of infections requiring hospitalization.

HIV-Infected Liver and Kidney Transplant Recipients: 1- and 3-Year Outcomes

“…It is our current practice to allow thymoglobulin induction therapy in kidney recipients as a result of the aggressive alloimmune response seen in this pilot study. However, serious non-OIs resulting in hospitalization were more common among those who required thymoglobulin treatment, and CD4+ T-cell counts often remain suppressed for months (20). In addition, there was an early sepsis-related death in a liver transplant recipient with hepatorenal syndrome who received thymoglobulin to facilitate renal recovery (unpublished data).…”

Survival of Liver Transplant Patients Coinfected with HIV and HCV Is Adversely Impacted by Recurrent Hepatitis C

“…A link between immunosuppression and recurrence of hepatitis C has been postulated (33), and we have purposely avoided the use of induction therapy with monoclonal antibodies in these patients so as not to increase HCV recurrence (17) and to avoid immunodepletion of T cells (34). Dual immunosuppression with tacrolimus and steroids was utilized, and the latter were typically weaned off within 6 months postoperatively.…”

Common Infections in Kidney Transplant Recipients

“…Notably, anti-thymocyte globulin results in profound and lasting CD4 suppression and should be restricted to patients with high immunologic risk for rejection (70,71). Monoclonal anti-IL2 receptor antibodies, such as basiliximab/ daclizumab, have been shown to increase CD4 counts and are used in some centers as induction therapy (70).…”