Correspondence

Renal Transplantation between HIV-Positive Donors and Recipients

N Engl J Med 2010; 362:2336-2337June 17, 2010

Article

To the Editor:

Nephropathy associated with infection with the human immunodeficiency virus (HIV) is the leading cause of end-stage renal disease (ESRD) in HIV-infected patients in South Africa.1,2 We practice in a resource-constrained environment where the use of dialysis is limited; as a result, many patients for whom dialysis would be appropriate are sent home to die. Decreasing availability of transplants from deceased donors and an increasing frequency of HIV infection among brain-dead donors compound the problem. Recent studies suggest that the outcome of renal transplantation is similar in HIV-infected and noninfected recipients when HIV-negative donor kidneys are used.3 However, the safety and effectiveness of transplanting a kidney from an HIV-positive donor into an HIV-infected recipient is undetermined.

At our hospital, we undertook four renal transplantations involving HIV-positive recipients and HIV-positive donors, from September through November 2008 (Table 1Table 1Clinical Characteristics of HIV-Positive Recipients of a Transplant from an HIV-Positive Donor.). The recipients had ESRD, were receiving antiretroviral therapy, had stable disease (defined as an HIV viral load of <50 copies per milliliter for >6 months), and had no previous opportunistic infections other than fully treated pulmonary tuberculosis (Patient 2). None had access to dialysis or an HIV-negative donor transplant within the state sector, because HIV was an exclusion criterion. The four transplants were from two deceased donors who had not received antiretroviral therapy, did not have a history of serious opportunistic infection or cancer, and had normal renal biopsies without evidence of proteinuria.

Recipients received antithymocyte globulin as induction therapy, prednisone, mycophenolate mofetil, and tacrolimus. One patient receiving tacrolimus had calcineurin toxicity and was switched to sirolimus. At 12 months after transplantation, all patients had good renal function, did not have clinically significant graft rejection, and have not needed dialysis since the procedure.

Transplantation programs in resource-limited settings cannot offer renal replacement to all patients who are in need. The use of HIV-infected donors would increase the donor pool, providing organs that otherwise would be discarded to recipients who would otherwise die of ESRD. The suitability of recipients depends on therapeutic, physical, and social attributes. All recipients must have proven adherence, virologic suppression, and immune reconstitution. Donor suitability is defined as HIV infection (confirmed with the use of enzyme-linked immunosorbent assay), absence of proteinuria, and a normal kidney as assessed with post hoc renal biopsy. To combat high rates of early acute rejection, antithymocyte globulin should be used. Prospective studies are needed to assess viral characteristics in donor–recipient pairs as factors for graft failure and disease progression.

We do not underestimate the potential for accelerating HIV disease progression by superinfecting the recipient with a different HIV clade or recombinant virus.4 Currently, HIV resistance rates are low in South Africa, and the use of antiretroviral therapy based on a boosted protease inhibitor in all recipients would increase the likelihood of suppressing any virus that is transplanted along with the kidney.

This report of four successful renal transplantations involving HIV-positive donors and recipients offers a new therapeutic approach to treating selected HIV-infected patients who have ESRD.

Elmi Muller, M.B., Ch.B.
Delawir Kahn, Ch.M.
Marc Mendelson, M.D., Ph.D.
Groote Schuur Hospital, Cape Town, South Africa
elmi.muller@uct.ac.za

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

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Citing Articles (8)

Citing Articles

1. 1

   N. Wearne, C. R. Swanepoel, A. Boulle, M. S. Duffield, B. L. Rayner. (2011) The spectrum of renal histologies seen in HIV with outcomes, prognostic indicators and clinical correlations. Nephrology Dialysis Transplantation
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2. 2

   B. J. Boyarsky, E. C. Hall, A. L. Singer, R. A. Montgomery, K. A. Gebo, D. L. Segev. (2011) Estimating the Potential Pool of HIV-Infected Deceased Organ Donors in the United States. American Journal of Transplantation 11:6, 1209-1217
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3. 3

   Camille Nelson Kotton. (2011) Judicious Choices: Outcomes of Organs From Seronegative Donors at Increased Risk for Viral Infection. Transplantation 91:11, 1183-1184
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4. 4

   Sanju Sobnach, Megan Borkum, Alastair J. W. Millar, Ross Hoffman, Elmi Muller, Fiona McCurdie, Delawir Kahn. (2011) Attitudes and beliefs of South African medical students toward organ transplantation. Clinical Transplantationno-no
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5. 5

   Lauren M Kucirka, Andrew L Singer, Dorry L Segev. (2011) High infectious risk donors: what are the risks and when are they too high?. Current Opinion in Organ Transplantation 16:2, 256-261
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6. 6

   Joan C Trullas, Federico Cofan, Montse Tuset, María J Ricart, Mercedes Brunet, Carlos Cervera, Christian Manzardo, María López-Dieguez, Federico Oppenheimer, Asuncion Moreno, Josep M Campistol, Jose M Miro. (2011) Renal transplantation in HIV-infected patients: 2010 update. Kidney International 79:8, 825-842
   CrossRef

7. 7

   Federico Cofan, Joan-Carles Trullas, Carlos Cervera, Federico Oppenheimer, Asuncion Moreno, Josep-Maria Campistol, Jose-Maria Miró. (2011) Are HIV-Infected Donors Suitable for Renal Transplantation?. Transplantation 91:4, e22-e23
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8. 8

   Robert Kalyesubula, Mark A. Perazella. (2011) Nephrotoxicity of HAART. AIDS Research and Treatment 2011, 1-11
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