Successful lung transplantation in an HIV seropositive patient with desquamative interstitial pneumonia: a case report

Abstract

BackgroundUntil recently, lung transplantation was not considered in patients with human immunodeficiency virus (HIV). HIV seropositive patients with suppressed viral loads can now expect long-term survival with the advent of highly active antiretroviral therapies (HAART); however, HIV remains a relative contraindication to lung transplantation. We describe, to our knowledge, the first HIV seropositive lung transplant recipient in Canada. We also review the literature of previously reported cases of solid-organ transplantation in patients with HIV with a focus on immunosuppression considerations.Case presentationA 48-year old man received a bilateral lung transplant for a diagnosis of desquamative interstitial pneumonia (DIP) attributed to cigarette and cannabis smoking. His control of HIV infection pre-transplant was excellent on HAART, and he had no other contraindications to lung transplantation. The patient underwent bilateral lung transplantation using basiliximab, methylprednisolone, and mycophenolate mofetil (MMF) as induction immunosuppression. He was maintained on MMF, prednisone, and tacrolimus thereafter, and restarted his HAART regimen immediately post-operatively. His post-transplant course was complicated by Grade A1 minimal acute cellular rejection, as well as an enterovirus/rhinovirus graft infection. Despite these complications, his functional status and control of HIV infection remain excellent 24 months post-transplant.ConclusionsOur patient is one of only several HIV seropositive lung transplant recipients reported globally. With growing acceptance of transplantation in this population, there is a need for clarification of prognosis post-transplantation, as well as optimal immunosuppression regimens for these patients. This case report adds to the recent literature that suggests HIV seropositivity should not be considered a contraindication to lung transplantation, and that post-transplant patients with HIV can be managed safely with basiliximab, tacrolimus, MMF and prednisone.

Selection Criteria for Lung Transplantation: Controversies and New Developments

“…[47][48][49][50][51] Good outcomes after liver, kidney, and heart transplantation have been reported, provided HIV patients were maintained on HAART. 47,51,52 Since the implementation of the HIV Organ Policy Equity (HOPE) Act in 2013, there have also been increasing reports of HIV positive to HIV positive kidney and liver transplantation. 50,[53][54][55] Yet, published cases of lung transplantation remain scarce (►Table 2).…”

“…57 CD4 þ cell counts and CD4 þ : CD8 þ ratios are therefore less useful for follow-up in HIV-infected patients, in contrast to HIV viral load (RNA). 52 Despite the scarce data on lung transplantation in HIV patients, we can carefully deduct from data on other solidorgan transplants that immunosuppression in this setting is safe. [51][52][53][54] HAART influences metabolism of calcineurin inhibitors, resulting in higher serum levels, making even more close monitoring of drug levels, as well as careful HAART tailoring (to avoid drug-drug interactions) necessary.…”

“…52 Despite the scarce data on lung transplantation in HIV patients, we can carefully deduct from data on other solidorgan transplants that immunosuppression in this setting is safe. [51][52][53][54] HAART influences metabolism of calcineurin inhibitors, resulting in higher serum levels, making even more close monitoring of drug levels, as well as careful HAART tailoring (to avoid drug-drug interactions) necessary. 51,52 Another problem is the higher relative risk of acute rejection.…”

“…[51][52][53][54] HAART influences metabolism of calcineurin inhibitors, resulting in higher serum levels, making even more close monitoring of drug levels, as well as careful HAART tailoring (to avoid drug-drug interactions) necessary. 51,52 Another problem is the higher relative risk of acute rejection. As ►Table 2 shows, all published cases of lung transplantation in HIV-positive patients show some level of acute cellular rejection (ACR); the reason for this is currently unclear.…”

“…51,56,58 In conclusion, notwithstanding the concerns mentioned earlier, HIV-positive patients who received lung transplantation achieved a short-term survival comparable to HIV-negative recipients, indicating that lung transplantation is feasible in carefully selected patients, immunosuppressant therapy can be adequately maintained when HAART is carefully tailored, and acute rejection can be well managed. 47,49,51,52,58 There is a need for systematic studies of this population to assess optimal immunosuppression and HAART therapy, as well as their long-term prognosis.…”