Outcomes of Kidney Transplantation in HIV-Infected Recipients

TLDR

Kidney transplantation outcomes in HIV‑positive patients are incompletely understood and generally fall between rates seen in older recipients and the overall transplant population. The study prospectively evaluated kidney transplantation outcomes in HIV‑positive candidates with CD4 ≥ 200 and undetectable viral load on stable antiretroviral therapy. The trial enrolled 150 HIV‑positive recipients, followed them for a median 1.7 years, and applied standardized protocols for infection prophylaxis, biopsy indications, immunosuppression, rejection management, and antiretroviral therapy. At 1 and 3 years, patient survival was 94.6 % and 88.2 % and graft survival 90.4 % and 73.7 %, yet rejection rates were high (31 % and 41 %), with graft loss associated with rejection treatment and antithymocyte globulin induction, while living‑donor transplants were protective and HIV remained well controlled. The study was funded by the National Institute of Allergy and Infectious Diseases (ClinicalTrials.gov NCT00074386).

Abstract

The outcomes of kidney transplantation and immunosuppression in people infected with human immunodeficiency virus (HIV) are incompletely understood.We undertook a prospective, nonrandomized trial of kidney transplantation in HIV-infected candidates who had CD4+ T-cell counts of at least 200 per cubic millimeter and undetectable plasma HIV type 1 (HIV-1) RNA levels while being treated with a stable antiretroviral regimen. Post-transplantation management was provided in accordance with study protocols that defined prophylaxis against opportunistic infection, indications for biopsy, and acceptable approaches to immunosuppression, management of rejection, and antiretroviral therapy.Between November 2003 and June 2009, a total of 150 patients underwent kidney transplantation; survivors were followed for a median period of 1.7 years. Patient survival rates (±SD) at 1 year and 3 years were 94.6±2.0% and 88.2±3.8%, respectively, and the corresponding mean graft-survival rates were 90.4% and 73.7%. In general, these rates fall somewhere between those reported in the national database for older kidney-transplant recipients (≥65 years) and those reported for all kidney-transplant recipients. A multivariate proportional-hazards analysis showed that the risk of graft loss was increased among patients treated for rejection (hazard ratio, 2.8; 95% confidence interval [CI], 1.2 to 6.6; P=0.02) and those receiving antithymocyte globulin induction therapy (hazard ratio, 2.5; 95% CI, 1.1 to 5.6; P=0.03); living-donor transplants were protective (hazard ratio, 0.2; 95% CI, 0.04 to 0.8; P=0.02). A higher-than-expected rejection rate was observed, with 1-year and 3-year estimates of 31% (95% CI, 24 to 40) and 41% (95% CI, 32 to 52), respectively. HIV infection remained well controlled, with stable CD4+ T-cell counts and few HIV-associated complications.In this cohort of carefully selected HIV-infected patients, both patient- and graft-survival rates were high at 1 and 3 years, with no increases in complications associated with HIV infection. The unexpectedly high rejection rates are of serious concern and indicate the need for better immunotherapy. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT00074386.).