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Good Kidney and Liver Transplant Results in Large Study of People With HIV
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6th IAS Conference on HIV Pathogenesis, Treatment and Prevention, July 17-20, 2011, Rome
Mark Mascolini
A 275-person analysis of HIV-positive people who underwent kidney and/or liver transplantation recorded excellent results for kidney recipients and prolonged survival for liver recipients with a model for end-stage liver disease (MELD) score of 15 or higher [1]. Hepatitis C virus (HCV) coinfection raised the risk of death with both procedures, and dual kidney/liver transplantation had the greatest impact on mortality after liver transplantation.
Understanding outcomes and risk predictors in HIV-positive people who have kidney or liver transplants is important because concerns about survival and infection risk still make some surgeons hesitant to perform transplants in people with HIV. But at the same time, liver and kidney disease have become increasingly common causes of morbidity and mortality in people living to an older age with HIV infection.
This multicenter US analysis involved 150 HIV-positive kidney transplant recipients with a CD4 count above 200 and an undetectable viral load and 125 liver transplant recipients with a CD4 count above 100 and an undetectable HIV load or anticipated post-transplant HIV control for people who could not tolerate antiretrovirals before transplant. The investigators assessed numerous predictors of survival and first serious nonopportunistic infection: age, gender, race, enrollment/pretransplant/current CD4 count, HIV load, MELD (for liver transplants), body mass index, thymoglobulin use, HCV, opportunistic infection, dual liver/kidney transplant, and donor characteristics.
Median follow-up measured 2.7 years after kidney transplantation and 2.3 years after liver transplantation. One-year survival (and 95% confidence interval [CI]) was 95% (90% to 98%) for kidney recipients and 80% (72% to 86%) for liver recipients. Respective 3-year survival rates were 91% (84% to 95%) and 67% (56% to 75%).
In kidney transplant patients, HCV coinfection tripled the risk of death (hazard ratio [HR] 3.17, 95% CI 1.10 to 9.09, P = 0.03) and older age (evaluated as a continuous variable) raised the death risk 6% (HR 1.06, 95% CI 1.01 to 1.11, P = 0.03). Initial use of thymoglobulin, a transplant rejection drug, more than doubled the risk of death (HR 2.63), but this association fell short of statistical significance (95% CI 0.94 to 7.31, P = 0.06).
In liver transplant patients, also having a kidney transplant raised the risk of death almost 5 times (HR 4.86, 95% CI 1.92 to 12.2, P = 0.0008). Four other variables more than doubled the death risk: pretransplant body mass index below 21 (HR 2.74, 95% CI 1.25 to 5.98, P = 0.01), donor age over 40 (HR 2.23, 95% CI 1.07 to 4.64, P = 0.03), HCV coinfection (HR 2.47, 95% CI 0.95 to 6.44, P = 0.06), and detectable viral load at enrollment (HR 2.07, 95% CI 0.89 to 4.81, P = 0.09). The last two associations fell short of statistical significance.
In an analysis that considered all eligible transplant candidates from the time of enrollment, liver transplantation significantly improved survival for people who underwent the procedure with a MELD score at or above 15 (HR 0.09, 95% CI 0.05 to 0.16, P < 0.0001) but not for those with a lower MELD score (HR 0.71, 95% CI 0.27 to 1.85, P = 0.48). Survival benefit also lacked significance after kidney transplantation (HR 0.67, 95% CI 0.31 to 1.45, P = 0.31). George Beatty (University of California, San Francisco), who presented the findings, suggested that the nonsignificant trends to improved survival may be explained by limited follow-up to date.
Fifty-two people (19%) had 90 opportunistic infections before transplantation, but that did not affect infection recurrence or survival after transplantation. Thirteen people (5%) had an opportunistic infection after transplantation. Seventy-seven kidney recipients (52%) and 70 liver recipients (56%) had a serious nonopportunistic infection (usually bacterial) after transplantation.
HCV coinfection more than doubled the risk of a serious nonopportunistic infection after both kidney transplantation (HR 2.27, 95% CI 1.33 to 3.87, P = 0 .003) and liver transplantation (HR 2.34, 95% CI 1.13 to 4.83, P = 0.02). In kidney recipients, initial thymoglobulin use doubled the risk of a serious nonopportunistic infection (HR 2.10, 95% CI 1.25 to 3.53, P = 0.01), while a higher nadir CD4 count lowered the risk about 7% (HR 0.93, 95% CI 0.87 to 1.00, P = 0.048).
Two factors cut the risk of serious nonopportunistic infection after liver transplantation, a higher latest CD4 count (HR 0.88, 95% CI 0.80 to 0.98, P = 0.02) and Caucasian race (HR 0.49, 95% CI 0.28 to 0.85, P = 0.01).
Beatty and colleagues believe their findings "indicate that HIV disease should not be considered a contraindication to transplantation," but they advised that transplant "selection criteria should include baseline factors contributing to outcome," such as body mass index and the need for dual transplantation. Some attendees wondered why kidney transplantation did not significantly prolong survival, while others wondered if a new kidney could be expected to prolong survival in wait-list people on dialysis. Beatty noted that dialysis carries its own morbidity and mortality risks.
Reference
1. Beatty G, Barin B, Fox L, et al. HIV-related predictors and outcomes in 275 liver and/or kidney transplant recipients. 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention. July 17-20, 2011. Rome. Abstract MOAB0105.
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