An October Wall Street Journal (WSJ) article highlights a new trend--an increase in the number of organ transplants in HIV-positive patients. Historically, centers have been reluctant to conduct vital organ transplants in these patients for a number of reasons. There have been concerns that recipients would not live long, that HIV-associated diseases would damage the transplanted organ and that anti-rejection drugs might degrade organ functions. However, highly effective anti-retroviral therapies (ART), available since the mid-1990s, have enhanced overall health and life expectancy (32.1 years after diagnosis) for HIV patients to such a degree that organ transplantation is now becoming a viable clinical option. In fact, aging HIV-positive patients are now encountering many of the same health issues as the general population, often necessitating liver, kidney and heart transplants.
“There are so many patients who are [HIV-positive] but are in good shape and look better than other patients that we transplant,” said Hiroo Takayama, MD, PhD, a surgeon at New York-Presbyterian Hospital/Columbia University Medical Center. Takayama has done two heart transplants in HIV-positive patients. “So the question is whether we really should eliminate those patients—should we let them die just because they are HIV-positive?” The center is currently conducting long-term post-transplant follow-ups on 11 HIV-positive people who have had heart transplants. This situation, as the WSJ piece notes, would have been unheard of five years ago.
According to the United Network for Organ Sharing, the nonprofit organization that manages the US transplant system, the number of centers that reported doing transplants on HIV-positive patients increased in 2011 to at least 48 out of the 242 that perform transplants. In contrast, only 25 centers reported conducting such procedures in 2005. The overall number of transplants may be even higher because some states prohibit reporting information relevant to HIV status. In addition, at least 198 HIV-positive patients received organ transplants in 2011, up from approximately 58 performed in 2005.
Evidence of the new trend can be found in such institutions as the Hartford Hospital (HH) in Connecticut. HH rewrote protocols earlier in 2012 to make possible the centers first heart transplant in an HIV-positive patient, a procedure barred under previous protocols. As part of the new protocol, a candidate needs to have taken anti-retroviral drugs for a minimum of one year and demonstrate undetectable viral loads. “There is a scarcity of donor hearts, and we want to make sure every patient will survive,” said Detlef Wencker, director of heart-failure services and cardiac transplantation at HH.
The WSJ article also acknowledged that hurdles still exist for HIV patients needing transplants. Physicians must carefully manage the complex interactions between ART and organ rejection drugs, plus the possible long-term effect on the health of the transplanted organ. Another red flag for doctors is the lack of available outcome data on transplants in HIV-positive patients. Existing data suggest that providers should be aware of potential complications. In a recently completed study, researchers at Massachusetts General Hospital found that patients with undetectable HIV levels had inflammation in their aortas comparable to people with known cardiovascular disease. Other studies suggest that HIV-infected patients are at twice the risk for heart attacks and strokes as their unaffected peers.
While providers continue to weigh the risks vs. rewards associated with organ transplants, a consensus seems to be that more long-term outcome data can only be beneficial. Transplant surgeon Peter Stock, MD, PhD, is professor of surgery at the University of California, San Francisco School of Medicine. He is principal investigator of a multicenter trial of kidney and liver transplants in HIV-positive patients. Findings from the trial, which was sponsored by the National Institutes of Health, showed that HIV-positive transplant patients responded well overall. Although Stock reported a two-to-three fold higher incidence of kidney rejection, he added that this incidence could be lowered by using immunosuppressant drugs.
Stock also stressed that the long-term health of the transplanted organ remains unknown but other health conditions “takes life out of the kidney.” While the effects might not show up in the short-term when measured against the general population, “we might start to see differences in survival in five or 10 years,” concluded Stock.
Source: The Wall Street Journal, October 11, 2012