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Should HIV+ Status Be a Contraindication to Transplantation?

  • Authors: News Author: Nancy A. Melville; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 2/18/2022
  • Valid for credit through: 2/18/2023, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for primary care physicians, transplant specialists, infectious disease specialists, nurses and other members of the healthcare team who treat and manage persons living with HIV infection.

The goal of this activity is to assess outcomes of liver and kidney transplantation among persons living with HIV.

Upon completion of this activity, participants will:

  • Assess the midterm outcomes of liver transplant among persons living with HIV
  • Evaluate long-term outcomes of kidney and liver transplant among persons living with HIV
  • Outline implications for the healthcare team


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News Author

  • Nancy A. Melville

    Freelance writer, Medscape


    Disclosure: Nancy A. Melville has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline; Johnson & Johnson

Editor/CME Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

CME/CE Reviewer/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

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Should HIV+ Status Be a Contraindication to Transplantation?

Authors: News Author: Nancy A. Melville; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 2/18/2022

Valid for credit through: 2/18/2023, 11:59 PM EST


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.

Kidney Transplant Patient Survival Lower, Graft Survival Similar

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).

Liver Transplant Patient Survival Similar

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.

Acute Rejection Rates Higher With HIV-Positivity vs National Averages

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.

Study Highlights

  • The study design was a retrospective review of patients receiving kidney or liver transplant at 1 US tertiary center from 2000 to 2019. The main study variable was HIV infection.
  • The main study outcomes were patient and graft survival among patients receiving kidney transplant, along with the rate of acute rejection. Researchers also followed patient survival among patients with liver transplant.
  • Study results were adjusted to account for patient and donor demographic factors as well as disease severity factors among graft recipients.
  • 119 HIV-positive adults were compared with 655 HIV-negative adults in the kidney transplant cohort. The mean age of these patients at the time of transplant was 52 years, and 70% of the cohort were men.
  • At 15 years after kidney transplant, patient survival rates were 79.6% and 53.6% in the HIV-negative and HIV-positive cohorts, respectively. The respective rates of graft survival were 57.0% and 75.0%. However, in adjusted analyses, patient and graft survival were similar, regardless of the presence of HIV infection.
  • Patient survival among kidney transplant patients was lower among persons living with HIV at 15 years. This result was influenced by a higher mortality rate among persons with coinfection with HCV and HIV, particularly those patients with kidney transplantation performed before the introduction of direct-acting antiviral therapy against HCV in 2014.
  • The liver transplant cohort included 80 patients with HIV and 440 patients without HIV infection. The average age of patients at the time of transplant was 53 years, and 66% were men.
  • Patient survival rates at 15 years in the liver transplant cohort were 60.3% in the group with HIV and 65.3% in the group without HIV. This difference was nonsignificant in adjusted analysis.
  • Again, persons coinfected with HIV and HCV had worse survival outcomes after liver transplant.
  • The incidence of acute rejection of kidney transplants exceeded 20% at 1 year and exceeded 30% by 3 years. The kidney graft survival rates among patients with HIV who had at least episode of acute rejection was 52.8% compared with a rate of 91.8% among patients without HIV infection.

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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