Correspondence

Organ Transplantation in HIV-Infected Patients

N Engl J Med 2002; 347:1801-1803November 28, 2002

Article

To the Editor:

Halpern et al. (July 25 issue)1 provided a compelling ethical rationale for pursuing transplantation in patients infected with the human immunodeficiency virus (HIV). Unfortunately, I believe they missed the point about why patients with HIV infection do not routinely undergo transplantation. We do not know how to do it. What immunosuppressive therapy should be used? What are the interactions of the immunosuppressive agents with the antiviral agents? What effect will immunosuppression have on the activity of HIV?

Rather than have 100 kidney centers each invent the wheel, several large centers with active involvement of infectious-disease specialists should perform transplantations in a substantial cohort of HIV-positive patients. These results should yield guidelines and suggestions for therapy. At least in renal transplantation, there is no excuse for multiple centers to make the same mistakes learning how best to treat this group of patients.

Charles E. Wright, M.D.
Victor D. Bowers, M.D.
LifeLink Transplant Institute, Tampa, FL 33606
charleswrightmd@netscape.net

1 References

1. 1

   Halpern SD, Ubel PA, Caplan AL. Solid-organ transplantation in HIV-infected patients. N Engl J Med 2002;347:284-287
   Full Text | Web of Science | Medline

To the Editor:

We agree with the point made by Halpern et al. about the radical change in the policy of organ transplantation in HIV-infected patients. We report the exceptional case of a 36-year-old woman with fulminant hepatic failure due to reactivation of a hepatitis B virus (HBV) infection by an HIV infection. Before transplantation, her HIV viral load was more than 350,000 copies per milliliter, and her CD4 cell count was 18 per cubic millimeter. We performed orthotopic liver transplantation, and postoperative treatment consisted of immunosuppression with tacrolimus, antiretroviral triple therapy, and treatment with hepatitis B immune globulin and lamivudine. Recurrence of HBV infection in HIV-infected patients has been prevented with hepatitis B immune globulin and lamivudine. In our patient, no major complications were observed during seven months of follow-up.

We believe that patients with HIV infection and end-stage liver disease may benefit from liver transplantation, which may be lifesaving.1,2 Although many questions about HIV and transplantation remain unanswered, revision of the attitudes that have excluded these patients from solid-organ transplantation is necessary.

Nermin Halkic, M.D.
Frank Bally, M.D.
Michel Gillet, M.D.
University Hospital of Lausanne, 1011 Lausanne, Switzerland
nhalkic@hospvd.ch

2 References

1. 1

   Bouscarat F, Samuel D, Simon F, Debat P, Bismuth H, Saimot AG. An observational study of 11 French liver transplant recipients infected with human immunodeficiency virus type 1. Clin Infect Dis 1994;19:854-859
   CrossRef | Web of Science | Medline

2. 2

   Ragni MV, Dodson SF, Hunt SC, Bontempo FA, Fung JJ. Liver transplantation in a hemophilia patient with acquired immunodeficiency syndrome. Blood 1999;93:1113-1114
   Web of Science | Medline

To the Editor:

Halpern et al. provide compelling arguments for expanding access to solid-organ transplants to HIV-infected patients. However, they do not discuss autologous hematopoietic stem-cell transplantation, which is currently being used for the treatment of HIV-associated lymphoma.1-5 Although the ethical issues regarding allocation of resources such as donor organs are obviated with the use of an autologous product, issues of insurance reimbursement and the risks of infection are similar.

We have developed an active program of autologous stem-cell transplantation for the treatment of HIV-related lymphoma.1,2 Initially, we were concerned that the myeloablative chemotherapy might worsen the underlying HIV infection and increase the rate of opportunistic infections. Furthermore, the effects of combining protease-inhibitor–based therapy with high-dose chemotherapy were unknown.

Since the initiation of the program in 1998, we have performed autologous stem-cell transplantation in 19 patients. After a median follow-up of about 2 years (range, 3 months to 53 months), 16 patients remain alive and in remission. One patient, who was elderly, died of transplant-related complications, and two patients died early of relapsed lymphoma. Infectious complications in the early period after transplantation in this group of patients have been similar to those in HIV-negative patients, and there appears to be no long-term adverse effect on the underlying HIV infection.

Amrita Krishnan, M.D.
Arturo Molina, M.D.
Stephen J. Forman, M.D.
City of Hope Cancer Center, Duarte, CA 91010
akrishnan@coh.org

5 References

1. 1

   Molina A, Krishnan AY, Nademanee A, et al. High dose therapy and autologous stem cell transplantation for human immunodeficiency virus-associated non-Hodgkin lymphoma in the era of highly active antiretroviral therapy. Cancer 2000;89:680-689
   CrossRef | Web of Science | Medline

2. 2

   Krishnan A, Molina A, Zaia J, et al. Autologous stem cell transplantation for HIV-associated lymphoma. Blood 2001;98:3857-3859
   CrossRef | Web of Science | Medline

3. 3

   Gabarre J, Azar N, Autran B, Katlama C, Leblond V. High-dose therapy and autologous haematopoietic stem-cell transplantation for HIV-1-associated lymphoma. Lancet 2000;355:1071-1072
   CrossRef | Web of Science | Medline

4. 4

   Gabarre J, Choquet S, Azar N, et al. High dose chemotherapy (HDC) with autologous stem cell transplantation (AST) for HIV-associated lymphoma (Ly): a single center report on 14 patients (pts). Blood 2001;98:502a-502a abstract.
   Web of Science

5. 5

   Campbell P, Iland H, Gibson J, Joshua D. Syngeneic stem cell transplantation for HIV-related lymphoma. Br J Haematol 1999;105:795-798
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We agree with Wright and Bowers that transplantation in HIV-infected patients should be initiated at large centers where infectious-disease specialists can work closely with transplantation teams. The experiences of these centers should then be made available to other centers as well as to investigators interested in comparing the outcomes in HIV-positive and HIV-negative recipients. We reiterate, however, that the procedure should not be considered experimental. Several large centers have already gained substantial experience with transplantation in HIV-infected patients and have had highly favorable results.1,2 In addition, strategies have been developed for reducing the doses of immunosuppressive agents when they are jointly administered with antiretroviral agents.3

Halkic and colleagues report their successful experience with liver transplantation in a patient with highly advanced HIV disease. This case provides further support for our position that a broad range of HIV-infected patients may be suitable candidates for transplantation.

Krishnan and colleagues report their experience with autologous stem-cell transplantation for the treatment of HIV-related lymphoma. We chose to limit our discussion to solid-organ transplantation because ethical issues about the use of scarce resources are more complex than those about the use of plentiful resources, such as autologous stem-cell transplants. Nonetheless, we fully agree that the use of autologous stem-cell transplantation in HIV-infected patients should be reimbursed by third-party payers to the same extent that it would be in noninfected patients. It represents yet another intervention the use of which in HIV-infected patients has been made possible by advances in antiretroviral therapy.

Scott D. Halpern, M.S.C.E.
University of Pennsylvania School of Medicine, Philadelphia, PA 19104
shalpern@cceb.med.upenn.edu

Peter A. Ubel, M.D.
Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI 48109

Arthur L. Caplan, Ph.D.
University of Pennsylvania School of Medicine, Philadelphia, PA 19104

3 References

1. 1

   Stock PG, Carlson L, Freise C, et al. Solid organ transplantation in HIV infected patients. Presented at the XIX International Congress of the Transplantation Society, Miami, August 25–30, 2002. abstract.
   

2. 2

   Kumar MSA, Damask A, Fyfe B, et al. Kidney transplantation (KTX) in HIV positive end-stage renal disease (ESRD) patients — a prospective study. Presented at the XIX International Congress of the Transplantation Society, Miami, August 25–30, 2002. abstract.
   

3. 3

   Jain A, Venkataramanan R, Shapiro R, et al. Profound interaction between tacrolimus, rapamycin and anti-HIV drugs in liver and kidney transplant patients. Presented at the XIX International Congress of the Transplantation Society, Miami, August 25–30, 2002. abstract.
   

Citing Articles (6)

Citing Articles

1. 1

   Prakash Vishnu, David M. Aboulafia. (2012) AIDS-Related Non-Hodgkin's Lymphoma in the Era of Highly Active Antiretroviral Therapy. Advances in Hematology 2012, 1-9
   CrossRef

2. 2

   Gwenn E. McLaughlin, Andrew C. Argent. 2011. Acquired Immune Dysfunction. , 1302-1314.
   CrossRef

3. 3

   Jerome Amir Singh. (2010) Organ transplantation between HIV-infected patients. The Lancet 375:9713, 442-443
   CrossRef

4. 4

   Kathy L Coffman. (2004) Evidence-based medicine: the dilemma of transplantation in patients with HIV infection. Current Opinion in Organ Transplantation 9:4, 422-427
   CrossRef

5. 5

   (2004) Solid organ transplantation in the HIV-infected patient. American Journal of Transplantation 4:s10, 83-88
   CrossRef

6. 6

   Arturo Molina, John Zaia, Amrita Krishnan. (2003) Treatment of human immunodeficiency virus-related lymphoma with haematopoietic stem cell transplantation. Blood Reviews 17:4, 249-258
   CrossRef