Outcomes of Kidney Transplantation in HIV-Infected Recipients
Year of Publication
Stock, P; Barin, B; Murphy, B; Hanto, D; Diego, J; Light, J; Davis, C; Blumberg, E; Simon, D; Subramanian, A; Millis, J; Lyon, G; Brayman, K; Slakey, D; Shapiro, R; Melancon, J; Jacobson, J; Stosor, V; Olson, J; Stablein, D; Roland, M
N Engl J Med
Adult; AIDS-Related Opportunistic Infections; CD4 Lymphocyte Count; Chemoprevention; Female; Graft Rejection; Graft Survival; HIV Infections; Immunosuppression; Immunosuppressive Agents; Kaplan-Meier Estimate; Kidney
Background The outcomes of kidney transplantation and immunosuppression in people infected with human immunodeficiency virus (HIV) are incompletely understood. Methods We undertook a prospective, nonrandomized trial of kidney transplantation in HIV-infected candidates who had CD4+ T-cell counts of at least 200 per cubic millimeter and undetectable plasma HIV type 1 (HIV-1) RNA levels while being treated with a stable antiretroviral regimen. Post-transplantation management was provided in accordance with study protocols that defined prophylaxis against opportunistic infection, indications for biopsy, and acceptable approaches to immunosuppression, management of rejection, and antiretroviral therapy. Results Between November 2003 and June 2009, a total of 150 patients underwent kidney transplantation; survivors were followed for a median period of 1.7 years. Patient survival rates (+/-SD) at 1 year and 3 years were 94.6+/-2.0% and 88.2+/-3.8%, respectively, and the corresponding mean graft-survival rates were 90.4% and 73.7%. In general, these rates fall somewhere between those reported in the national database for older kidney-transplant recipients (>/=65 years) and those reported for all kidney-transplant recipients. A multivariate proportional-hazards analysis showed that the risk of graft loss was increased among patients treated for rejection (hazard ratio, 2.8; 95% confidence interval [CI], 1.2 to 6.6; P=0.02) and those receiving antithymocyte globulin induction therapy (hazard ratio, 2.5; 95% CI, 1.1 to 5.6; P=0.03); living-donor transplants were protective (hazard ratio, 0.2; 95% CI, 0.04 to 0.8; P=0.02). A higher-than-expected rejection rate was observed, with 1-year and 3-year estimates of 31% (95% CI, 24 to 40) and 41% (95% CI, 32 to 52), respectively. HIV infection remained well controlled, with stable CD4+ T-cell counts and few HIV-associated complications. Conclusions In this cohort of carefully selected HIV-infected patients, both patient- and graft-survival rates were high at 1 and 3 years, with no increases in complications associated with HIV infection. The unexpectedly high rejection rates are of serious concern and indicate the need for better immunotherapy.
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