Effects of immunosuppressive drugs on HIV infection: implications for solid-organ transplantation

Abstract

Summary With the advent of highly active antiretroviral therapy (HAART), HIV infection has become a chronic disease. Various end‐stage organ failures have now become common co‐morbidities and are primary causes of mortality in HIV‐infected patients. Solid‐organ transplantation therefore has been proposed to these patients, as HIV infection is not anymore considered an absolute contraindication. The initial results of organ transplantation in HIV‐infected patients are encouraging with no differences in patient and graft survival compared with non‐HIV‐infected patients. The use of immunosuppressive drug therapy in HIV‐infected patients has so far not shown major detrimental effects, and some drugs in combination with HAART have even demonstrated possible beneficial effects for specific HIV settings. Nevertheless, organ transplantation in HIV‐infected patients remains a complex intervention, and more studies will be required to clarify open questions such as long‐term effects of drug interactions between antiretroviral and immunosuppressive drugs, outcome of recurrent HCV infection in HIV‐infected patients, incidence of graft rejection, or long‐term graft and patient survival. In this article, we first review the immunological pathogenesis of HIV infection and the rationale for using immunosuppression combined with HAART. We then discuss the most recent results of solid‐organ transplantation in HIV‐infected patients.

Heart Transplantation in Human Immunodeficiency Virus–Positive Patients

“…In contrast, liver and kidney transplantation have been performed much more frequently in HIV-positive patients, with good clinical results. 8 Currently, a multcenter study sponsored by the National Institutes of Health is underway to evaluate the safety and efficacy of kidney and liver transplantation in a select population of HIV-infected individuals. Unfortunately, HIV-positive end-stage heart failure patients are not included.…”

Common Infections in Kidney Transplant Recipients

“…The choice of immunosuppressive medication may have a substantial effect on HIV management (69,70). 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).…”

“…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).…”

Infections After Kidney Transplantation: The Bug Bear Of Kidney Transplantation In Tropics

“…Protease inhibitors are usually not used in such patients, to avoid drug interactions. In view of profound CD4 suppression [105], Thymoglobulin is reserved for the most immunologic high risk HIV recipients [104]. However, IL2 blockers such as basiliximab, tacrolimus and MMF are the preferred immunosuppressive drugs in HIV infected KTRs [106].…”