In the last decade or so in the United States, HIV infection has been transformed from a life-ending disease to a life-changing one. With the development of Highly Active Anti-Retroviral Therapy (HAART), HIV-positive patients are living longer, and in so doing, confronting the new challenge of coping with chronic conditions.
One of these conditions is end stage renal disease (ESRD) which has led to consideration of HIV-positive patients' candidacy for kidney transplants.
Doctors at the Hopkins School of Medicine wanted to know how HIV-positive patients undergoing kidney transplantation fare compared to HIV-negative patients who undergo the same procedure. Their results were published in Archives of Surgery this month.
"The role for kidney transplantation among HIV-positive ESRD patients is under consideration, but concerns remain regarding allocation of kidneys to these patients when long-term benefit has not been firmly established," lead author of the study Jayme Locke said in an e-mail interview.
"The goal of our study was to determine whether or not HIV-positive kidney transplant recipients can have long-term graft survival comparable to their HIV-negative counterparts."
Locke and her team expected that HIV-positive patients might have lower one-year kidney graft survival than HIV-negative patients based on their already immuno-compromised condition. What the research implies, however, is not exactly that.
"We found that while long-term allograft survival is lower among HIV-positive recipients, controllable risk factors may explain this disparity," Locke said.
So, while graft survival is lower in HIV-positive patients, the factors that cause this disparity can be addressed.
"With proper donor selection and recipient management, including the avoidance of prolonged cold ischemic (organ preservation before surgery) time, utilization of living donors and determination of optimal immunosuppression dosing prior to transplantation, long-term graft survival comparable to HIV-negative recipients can be achieved," Locke said.
In fact, the researchers found that results of transplantation were equally good for HIV-positive and negative patients when kidney donors were under 50 years old.
This is good news for HIV-positive patients with ESRD, and it doesn't stop there.
"Historically, there have been concerns about the potential additive effect of immunosuppression agents and HIV on the risk for opportunistic infections and malignancy, and the potential for acceleration of HIV infection in the setting of decreased immune surveillance," Locke said.
The study done by Locke and colleagues was small because of the scarcity of HIV-positive patients receiving kidney transplants, and therefore, presented a few challenges.
"Several additional sensitivity analyses were required. These analyses were necessary because of the relatively small number of HIV-positive kidney transplants that have ever been performed (approximately 100)," Locke said. "Multivariate models based on small sample sizes are inherently unstable and can result in overfitting of the model. Our results, however, were robust to all sensitivity analyses."
In order to address the obstacles created by small sample size, Locke and his team are involved in a bigger, multi-center trial that aims to "collect more detailed information about HIV-positive recipients so that the impact of transplant immunosuppression and HAART on long-term outcomes, including patient and graft survival and infectious complications, can be better understood," Locke said.
The outcome of this study may be exciting for doctors and HIV-positive patients with ESRD because previously, small-scale studies have found that certain interventions, like cyclosporine-based immunosuppression, a method for decreasing organ rejection, either don't affect or inhibit the progression of HIV to AIDS in HIV-positive kidney transplant patients.
