Evolving Clinical Strategies for Transplantation in the HIV-Positive Recipient

Abstract

The transplant community has been slow to recognize the efficacy of highly active antiretroviral therapy in changing the course of human immunodeficiency virus (HIV) infection to a chronic condition. People infected with HIV are dying less often from progression of HIV to acquired immune deficiency syndrome. Unfortunately, there is an increasing rate of morbidity and mortality from comorbidities resulting in end-stage liver and kidney disease, prompting some transplant centers to eliminate HIV infection as a contraindication to transplantation. This overview will describe the evolving clinical strategies that have resulted in good outcomes after solid organ transplantation in the HIV-positive recipient.

Renal Transplantation in HIV-Positive Recipients

“…Occasionally, during the peritransplant period, patients are unable to tolerate HAART therapy. Current recommendations are to stop HAART immediately in this setting to avoid development of drug-resistant strains, because the cessation of HAART can be tolerated for several weeks without changes in viral load or CD4 count [19,28].…”

“…Traditionally, HIV infection has been considered an absolute contraindication to solid-organ transplantation. However, in the context of improved survival [18], the role for kidney transplantation among HIV-positive patients is currently being revisited [19]. In the following sections, long-term outcomes after kidney transplantation in the HAART era are discussed and management strategies for the HIV-positive kidney transplant recipient are reviewed.…”

Human Immunodeficiency Virus disease and cardiac surgery – where are we?

“…Recognising availability of more information, but no long term follow up, they are doubtful about suitability in view of increasing donor shortages. (38) Stock and Roland, (48) Cardiac transplantation in the HIV situation is under discussion in South Africa (49) where again, the advent of ARV/HAART was markedly delayed, and the Public Health System has failed.…”

“…(36) Everson Uip's series (12) listed 5 congenital heart HIV DISEASE AND SURGERY (39) regarded the last concern as "a fi nal major barrier to transplantation". Interestingly, some immune suppressants such as cyclosporine, also suppress the virus.…”

Update on kidney transplantation in human immunodeficiency virus infected recipients

“…Inappropriate levels of CD4 T cell count and viral load were reported in 30% of cases and two-thirds of patients were excluded because of cardiovascular diseases or diabetes [24] . Generally accepted criteria for listing HIV positive patients for kidney transplantation are shown in Table 2 [ 25,26] . An exception is usually given to certain treatable and preventable infections such as tuberculosis, esophageal candidiasis, and Pneumocystis jiroveci pneumonia.…”