Identification of Optimal Donor–Recipient Combinations Among Human Immunodeficiency Virus (HIV)–Positive Kidney Transplant Recipients

Abstract

For some patient subgroups, HIV-infection has been associated with worse outcomes after kidney transplantation (KT); potentially modifiable factors may be responsible. The study goal was to identify factors that predict a higher risk of graft loss among HIV+ KT recipients compared with a similar transplant among HIV− recipients. 82,762 deceased donor KT (HIV+: 526; HIV−: 82,236) reported to SRTR (2001–2013) were studied by interaction term analysis. Compared to HIV− recipients, HCV amplified risk 2.72-fold among HIV+ KT recipients (aHR: 2.72, 95%CI: 1.75–4.22, p<0.001); and 43% of the excess risk was attributable to the interaction between HIV and HCV (AP: 0.43, 95%CI: 0.23–0.63, p=0.02). Among HIV+ recipients with >3 HLA mismatches (MM), risk was amplified 1.80-fold compared to HIV− (aHR: 1.80, 95% CI: 1.31–2.47, p < 0.001); and 42% of the excess risk was attributable to the interaction between HIV and >3 HLA MM (AP: 0.42, 95%CI: 0.24–0.60, p=0.01). High-HIV-risk (HIV+/HCV+ & >3 HLA MM) recipients had a 3.86-fold increased risk compared to low-HIV-risk (HIV+/HCV− & ≤3 HLA MM) recipients (aHR: 3.86, 95%CI: 2.37–6.30, p< 0.001). Avoidance of >3 HLA mismatches in HIV+ KT recipients, particularly among co-infected patients, may mitigate the increased risk of graft loss associated with HIV-infection.

Disparity in access to kidney allograft offers among transplant candidates with human immunodeficiency virus

“…It is not surprising that the majority of organs offered to HIV+ and HIV/HCV+ candidates met PHS increased risk criteria; however, the similarity in KDPI among accepted offers was unexpected, particularly given that HIV+ and HIV/HCV+ candidates were younger and less likely to have diabetes. Organ quality has been shown to have a significant impact on outcomes for HIV+ kidney and liver recipients, calling into question this practice, and suggesting that accepting physicians should balance access to transplantation for HIV+ candidates while being cognizant of their need for good quality organs.…”

Donor evaluation in the era of HIV-positive organ transplantation: The importance of the infectious diseases specialist

“…When evaluating HIV‐positive donors, expertise in the management of HIV‐positive transplantation is strongly encouraged 3 but general ID providers should be familiar also so as to assist in the decision‐making process 4,5 . Complete evaluation of potential HIV‐positive donors necessarily goes beyond the standard donor evaluation 6,7 .…”

Recent advances in kidney transplantation: a viewpoint from the Descartes advisory board*

“…Recently, United Network for Organ Sharing (UNOS) has introduced a system of allocation based on the biological age of the kidney, whereby the 20% of the best deceased donor kidneys according to the Kidney Donor Performance Index are allocated to the 20% recipients with the longest estimated post-transplant survival to avoid futility [ 11 ]. HIV-positive deceased donors are allocated to HIV-positive recipients, an approach recently expanded to live donor transplantation between HIV-positive donor recipient pairs [ 12 , 13 ]. In order to further improve matching by enlarging the donor pool, developing a mixed exchange model involving deceased and live donors could be very promising.…”