Clinical Context

For years, persons living with HIV infection were denied liver and kidney transplantation, largely because of a fear of worse outcomes given the presence of HIV infection. But a previous study by Roland and colleagues, published in the January 28, 2016, issue of AIDS, provided reassurance that transplant outcomes among persons living with HIV are generally similar to those among adults without HIV infection.^[1]

Researchers compared outcomes of HIV-positive transplant recipients and candidates and then compared outcomes of transplants among persons living with HIV vs those without HIV. Liver transplant was associated with a survival benefit among persons with HIV who had a model for end-stage liver disease (MELD) score of 15 or more, but not among those adults with a MELD score less than 15. Overall, there was a mild 6.7% increase in the risk for graft loss or death associated with HIV infection.

These results suggest that liver transplant should be considered for persons living with HIV, as long as liver disease severity is moderate to severe. Still, there are limited data regarding the long-term outcomes of liver and kidney transplants among persons living with HIV. This issue is addressed in the current study.

Study Synopsis and Perspective

Liver or kidney transplant recipients who are HIV-positive show outcomes that are similar to those without HIV at 15 years posttransplant in new research that represents some of the longest follow-up on these patients to date.

The findings further support the inclusion of people with HIV in transplant resource allocation, say the researchers.

"Overall, the excellent outcomes following liver and kidney transplant recipients in HIV-infected recipients justify the utilization of a scarce resource," senior author Peter G. Stock, MD, PhD, surgical director of the Kidney and Pancreas Transplant Program and surgical director of the Pediatric Renal Transplant Program at the University of California San Francisco (UCSF), told Medscape Medical News.

"Many centers still view HIV as a strict contraindication [for transplantation]. This data shows it is not," he emphasized.

The study, published this week in JAMA Surgery, involved HIV-positive patients who received kidney or liver transplants between 2000 and 2019 at UCSF, which has unique access to some of the longest-term data on those outcomes.^[2]

"UCSF was the first US center to do transplants routinely in people with HIV, and based on the large volume of transplants that are performed, we were able to use propensity matching to address the comparison of HIV-positive and -negative liver and kidney transplant recipients at a single center," Dr Stock explained.

"To the best of our knowledge, there are no long-term reports [greater than 10 years] on [transplant] outcomes in the HIV-positive population."

Commenting on the study, David Klassen, MD, chief medical officer of the United Network for Organ Sharing, noted that the findings "confirm previous research done at UCSF and reported in the New England Journal of Medicine," in 2010, he told Medscape Medical News.^[3] "It extends the previous findings."

"The take-home message is that these HIV-positive patients can be successfully transplanted with expected good outcomes and will derive substantial benefit from transplantation," Dr Klassen said.

For the kidney transplant analysis, 119 HIV-positive recipients were propensity matched with 655 recipients who were HIV-negative, with the patients' mean age about 52 years and approximately 70% men.

At 15-years posttransplant, patient survival was 53.6% among the HIV-positive patients vs 79.6% for HIV-negative patients (P=.03).

Graft survival among the patients with kidney transplants was proportionally higher among HIV-positive patients after 15 years (75.0% vs 57.0%), but the difference was not statistically significant (P=.77).

First author Arya Zarinsefat, MD, from the Department of Surgery at UCSF, speculated that the lower long-term patient survival among HIV-positive kidney transplant recipients may reflect known cardiovascular risks among those patients.

"We postulated that part of this may be due to the fact that HIV-positive patients certainly have additional comorbidities, specifically cardiovascular" ones, he told Medscape Medical News.

"When looking at the survival curve, survival was nearly identical at 5 years, and only started to diverge at 10 years post-transplant," he noted.

A further evaluation of patients with HIV who were coinfected with hepatitis C (HCV) showed that those with HIV-HCV coinfection before the center's introduction of anti-HCV direct-acting antiviral medications in 2014 had the lowest survival rate of all subgroups, at 57.1% at 5 years posttransplant (P=.045 vs those treated after 2014).

In terms of liver transplant outcomes, among 83 HIV-positive recipients who were propensity-matched with 468 HIV-negative recipients, the mean age was about 53 years and about 66% were men.

The patient survival rates at 15 years were not significantly different between the groups, at 70.0% for the HIV-positive and 75.7% for the HIV-negative patients (P=.12).

Similar to the kidney transplant recipients, the worst survival among all liver transplant subgroups was among HIV-HCV coinfected patients before access to HCV direct-acting antivirals in 2014, with a 5-year survival of 59.5% (P=.04).

"Since the advent of HCV direct-acting antivirals, liver transplant outcomes in HCV monoinfected patients are comparable to HCV/HIV coinfected recipients," Dr Stock said.

The rates of acute rejection at 1 year in the kidney and liver transplant, HIV-positive groups, at about 20% and 30%, respectively, were, however, higher than national average incidence rates of about 10% at 1 year.

Long-term data on those patients showed the acute rejection affected graft survival outcomes with kidney transplant recipients: HIV-positive kidney transplant recipients who had at least 1 episode of acute rejection had a graft survival of just 52.8% at 15 years posttransplant compared with 91.8% among recipients without acute rejection.

Such differences were not observed among HIV-positive liver transplant recipients.

The authors note that the increased risk for acute rejection in HIV-positive kidney transplant patients is consistent with previous studies, with causes that may be multifactorial.

Top theories include drug interactions with protease inhibitors, resulting in some centers transitioning HIV-infected patients from those regimens to integrase-based regimens before transplant.

"The management and prevention of [acute rejection] in HIV-positive [kidney transplant patients] will therefore continue to be a key component in the care of these patients," the authors write.

The study was supported in part by the National Institutes of Health. The study authors and Dr Klassen have disclosed no relevant financial relationships.

JAMA Surgery. Published online January 5, 2022.

Clinical Implications

• A previous study found that liver transplant was associated with a survival benefit among persons with HIV who had MELD score of 15 or more, but not among those adults with a MELD score less than 15. Overall, there was a mild 6.7% increase in the risk for graft loss or death associated with HIV infection compared with not having HIV infection.
• The current study finds that HIV infection status does not substantially affect graft or patient survival after kidney and liver transplant. Patients with HIV infection had reduced kidney graft survival after acute rejection of kidney transplant compared with persons without HIV.
• Implications for the healthcare team: The healthcare team should not use well-controlled HIV infection as a reason to delay necessary kidney and liver transplants.

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