- Researchers in San Francisco monitored people who received transplanted organs
- People with HIV did not have more transplant-related complications than people without HIV
- But some people with HIV died prematurely due to complications arising from heart disease
Thanks to effective HIV treatment (ART), many people with HIV are living longer. The power of ART is so tremendous that researchers predict that many ART users will have near-normal life expectancy. As people with HIV grow older, they become susceptible to aging-related issues, such as cardiovascular disease, and consequences of long-standing co-infections and underlying conditions. Collectively, these issues can lead to kidney and liver injury.
Organ transplantation
To the immune system of a person who receives an organ transplant, the organ appears foreign. As a result, the person’s immune system attacks it. In order for a transplanted organ to survive, the recipient’s immune system must be sufficiently weakened so that it does not attack the transplanted organ. Yet too much immune suppression can harm the person with the transplanted organ, making them susceptible to serious infections. Thus, a fine balance in the dosing of immune suppressive therapy is needed. In the era before ART became available, organ transplantation was not routinely done in people with HIV because of concerns about the effect of further immune suppression, their overall shorter life expectancy and other issues.
However, once ART became widely available in high-income countries, doctors could see that the immune systems of many ART users got stronger, and organ transplantation became a possibility for some people with HIV.
In San Francisco
Clinics associated with the University of California at San Francisco (UCSF) have been pioneers in conducting research with people who have HIV. One aspect of this research has been organ transplantation.
A team of researchers at UCSF reviewed health-related information that was collected over two decades (2000 to 2019) from people who had kidney and liver transplants. They compared outcomes between HIV-positive and HIV-negative people. The researchers found broadly similar rates of long-term survival regardless of HIV status.
Once potent oral antiviral drugs for hepatitis C virus (HCV) infection became available in 2014, improved outcomes were observed in people with HCV.
Despite the good news about the long-term survival of people with HIV who received organ transplants, the doctors noted that some people with HIV who received kidney transplants died prematurely (about 10 years after their transplant). These deaths were not due to complications of transplantation. Rather, the researchers think that the deaths were likely due to cardiovascular disease.
The present study was designed primarily to assess overall survival of people with HIV after transplantation and it showed that, in general, ART users can do quite well. However, some people with HIV remain vulnerable to cardiovascular disease and more attention needs to be paid to preventing and treating this issue.
Study details
In this study, researchers noted that many participants with HIV had underlying conditions that degraded the health of their kidneys and/or liver. In the case of people who needed a transplanted kidney, HIV itself could cause kidney injury, but there were other issues, such as high blood pressure and diabetes, that also contributed to injury of this organ. Among people with HIV who needed a liver transplant, issues such as liver cancer and co-infection with HCV played a role in injuring the liver.
Researchers reviewed their databases and compared the health outcomes of the following groups of people:
Kidney transplant recipients
- HIV positive – 119 people
- HIV negative – 655 people
Liver transplant recipients
- HIV positive – 83 people
- HIV negative – 468 people
As mentioned earlier, a fine balance must be achieved with drugs used to suppress the immune system so that it does not attack the transplanted organ. Too much immune suppression can lead to the development of serious and even life-threatening infections. Too little immune suppression can lead to the immune system launching an attack on the transplanted organ. The technical term for this is acute rejection.
Results – Kidneys
The researchers noted that for the first decade after transplantation, survival was approximately as follows:
- HIV-positive people – 70%
- HIV-negative people – 85%
However, 15 years after kidney transplantation, the proportions of people surviving were as follows:
- HIV-positive people – 54%
- HIV-negative people – 80%
Thus, there were significant excess deaths among people with HIV beginning about a decade after their kidney transplantation
The researchers stated that these excess deaths were “likely related to long-term cardiovascular HIV/AIDS-related comorbidities.” That is, because people with HIV are at heightened risk for cardiovascular disease, it is likely that this comorbidity played a role in their demise. Recall that some of the people who required a kidney transplant had underlying conditions such as diabetes and high blood pressure. These two conditions could have worsened their heart health in the long-term.
Unfortunately, the study was not designed to assess aspects of cardiovascular disease, so no further information was provided.
Results – Liver
The proportions of people surviving 15 years after liver transplantation were as follows:
- HIV positive – 70%
- HIV negative – 76%
Researchers found that from 2014, when potent oral anti-HCV drugs became available, outcomes after liver transplantation were similar whether or not people had pre-existing HCV infection (or co-infection in the case of people with HIV).
Rejection of transplanted organs
Episodes of rejection are relatively common after an organ transplant. If such episodes are caught early, increasing the dose of immune suppressive drugs or adding a new immune suppressive medicine can help to resolve the episode of rejection.
About 30% of participants who received a liver or kidney had an episode of acute rejection. This is higher than expected and possibly due to the type of immune suppression used by UCSF clinics. People with HIV were more likely to have acute rejection and, subsequently, chronic rejection, which degraded the health of the transplanted organ.
Bear in mind
This study is one of the longest to monitor people with HIV after an organ transplant. According to the researchers, “the results of this study show that kidney and liver transplant in HIV-positive patients have comparable long-term [organ] and patient survival to HIV-negative patients.”
They further stated: “The findings, in combination with previously published work, support providing organ transplant to HIV-positive patients, which the study team believes is an appropriate use of transplant resources and provides equitable access to these resources for HIV-positive patients.”
The present study was retrospective in design and limited to one medical centre. In the years ahead, other clinics in other locations will present long-term data from more HIV-positive people who have had organ transplants, and a fuller picture of their survival will emerge.
—Sean R. Hosein
Resources
HIV and cardiovascular disease – CATIE
Exploring the issue of heart attack in HIV – CATIE News
Trends in non-HIV dementia in people on HIV treatment (ART) in the U.S. – CATIE News
Is substance use disorder linked to increased cardiovascular disease risk? – CATIE News
Prévention des maladies cardiovasculaires – l’Institut de Cardiologie de Montréal
Heart attack – Public Health Agency of Canada
For professionals: Heart diseases and conditions – Government of Canada
Heart & Stroke – Heart and Stroke Foundation
Quitting smoking: Deciding to quit – Government of Canada
REFERENCE:
Zarinsefat A, Gulati A, Shui A, et al. Long-term outcomes following kidney and liver transplant in recipients with HIV. JAMA Surgery. 2022; in press.