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Four to Five HIV+ Dying in Care Yearly in
Philadelphia Are Potential Organ Donors
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ICAAC 2014. September 5-9, 2014. Washington, DC
Mark Mascolini
Four to 5 HIV-positive people dying in care in Philadelphia every year may be potential kidney or liver donors for others with HIV, according to a 6-clinic analysis [1]. The organs available would have somewhat reduced quality compared with organs donated by HIV-negative people, but they could trim the waiting list of HIV-positive people who need a kidney or liver.
Surgeons at a single South African center have transplanted 29 kidneys from HIV-positive donors to HIV-positive recipients [2]3. Five-year patient survival stands at 74%, and viral loads have remained undetectable in transplant recipients. (Four of these cases are reviewed in reference 3.)
Researchers who conducted the Philadelphia study reported that the US waiting list for organ transplants tops 123,000, but only 11,844 people got organ transplants from January through May of 2014. HIV-positive people, they noted, have worse outcomes on the waiting list than people without HIV.
In 2013 the US Congress passed the HIV Organ Policy Equity (HOPE) Act to encourage research into the feasibility of organ donation from HIV-positive people [4]. Researchers conducted this chart review to estimate how many potential HIV-positive organ donors die in care every year in Philadelphia and how many kidneys and livers might be available from those donors for people with HIV.
The research team reviewed charts of all HIV-positive people cared for at six large Philadelphia HIV clinics who died from January 2009 through June 2014. They reviewed patient demographics, HIV history, cause of death, and illnesses affecting donor suitability. People with at least two CD4 counts and/or viral loads measured at least 90 days apart and within 12 months of death were defined as in care.
The Philadelphia team rated HIV-positive people as potential donors if they (1) had documented brain death, (2) were under 70 years old, (3) had no malignancy, (4) were negative for hepatitis B surface antigen, (5) had no active opportunistic infections, and (6) had an HIV load below 200 copies. They focused on potential kidney or liver donors.
Among 508 people who died in care during the study period, median age stood at 53 (range 21 to 87). Two thirds were men, 73% African American, 19% Caucasian, and 6% Hispanic. Almost one third (31%) had cancer, and 44% were positive for HCV antibody. Nearly two thirds (63%) had a viral load below 200 copies, 56% had a CD4 count above 200, and 20% had evidence of antiretroviral resistance.
Of the 508 people who died in care, 173 died in the hospital, 110 died while on mechanical ventilation, and 23 were documented brain dead.* Of those 23, the researchers eliminated 3 with a history of malignancy and 7 with a viral load above 200 copies. That left 13 potential donors whose median age stood at 53 and ranged from 28 to 68. Seven died of anoxia, 4 of stroke, and 2 of head trauma. Eight potential donors had hypertension, 7 had HCV antibody, 6 had diabetes, 3 had cirrhosis, and 2 had end-stage renal disease. Last CD4 count stood at a median of 319 and ranged from 168 to 907. Four potential donors had an opportunistic infection history and 2 had resistance mutations.
The researchers estimated potential organ yield from these possible donors with models prepared by the Scientific Registry of Transplant Recipients based on all eligible donors form January 2012 through December 2013. They figured that the 13 potential donors could provide 9 livers (95% confidence interval [CI] 5 to 11) and 7 kidneys (95% CI 3 to 11). When the investigators extrapolated those results to the Philadelphia HIV population, they reckoned there might be 4 to 5 potential HIV-positive deceased donors per year who might provide 2 to 3 kidneys and 3 to 4 livers per year.
With other models designed to predict organ graft survival based on traits of donors and recipients, the Philadelphia collaborators estimated potentially available kidneys had an 80% increased risk of graft failure versus median transplanted kidneys in 2013. Predicted median risk of delayed graft function ranged from 22% to 40% based on recipient characteristics. Models created to predict liver graft survival indicated a 70.6% 3-year graft survival with livers from their potential donors versus 73.5% for median deceased liver donors from the same period. Factors contributing to reduced kidney or liver quality in these analyses were older age of potential donors, African-American race, and high rates of hypertension, diabetes, and HCV.
The investigators listed three unknown implications of HIV-related factors in potential donors: (1) HIV resistance mutations, (2) transmission of latent opportunistic infections, and (3) the potential need to continue protease inhibitors--which often interact with antirejection drugs--in recipients of organs from donors taking protease inhibitors.
The researchers noted that Philadelphia's transplant waiting list includes about 80 to 100 people with HIV. So the 2 to 3 kidneys and 3 to 4 livers from HIV-positive donors that might be available yearly would have a small but important impact on the waiting list. But the Philadelphia team cautioned those organs could have reduced quality. An obvious way to increase HIV-positive organ donations is for more people with HIV to document their wish to be an organ donor, especially people without many comorbidities.
*Presenting author Aaron Richterman (University of Pennsylvania) explained to NATAP that preferred candidates for organ donation are those declared brain dead while supported by mechanical ventilation and while the heart is still beating because continued blood flow ensures the highest-quality organ. A person who has indicated a wish to be an organ donor and dies with a devastating neurologic injury would be evaluated for brain death.
References
1. Richterman A, Lee D, Reese P, et al. Suitability of HIV infected patients for deceased organ donation. ICAAC 2014. September 5-9, 2014. Washington, DC. Abstract 1199a.
2. Odim J. The HOPE Act: criteria for transplanting kidneys or livers from HIV+ donors to HIV+ recipients. ICAAC 2014. September 5-9, 2014. Washington, DC. Abstract 1200.
3. Muller E, Kahn D, Mendelson M. Renal transplantation between HIV-positive donors and recipients. N Engl J Med. 2010;362:2336-2337. http://www.nejm.org/doi/full/10.1056/NEJMc0900837
4. NATAP. Various reports collated. July 2013. http://www.natap.org/2013/HIV/072213_02.htm
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