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Transplantation in HIV Michelle Roland, MD Assistant Professor of Medicine UCSF Positive Health Program at SFGH Background • HIV-infected patients have been excluded from consideration for transplantation because: 1. Morbidity too high to justify organ use 2. Immunosuppression might accelerate HIV disease • Mortality is reduced with HAART • Prospective study will evaluate: 1. Effect of immunosuppression on survival and HIV disease 2. Effect of HIV on graft survival 3. Drug interactions between PI/NNRTI and immunosuppressives • Many centers transplanted patients prior to the study Methods • Prospective analysis of enrolled subjects + • Retrospective review of recipients at study centers • “Eligible” subjects: • No opportunistic infection history • CD4 > 200 kidney; >100 liver • HIV RNA < 50 kidney, liver or unable to tolerate ARVs in liver but post-transplant suppression predicted • “Ineligible” subjects: • Did not meet 1 or more criteria above Results: Baseline • 41 “Eligible” Subjects • 22 Kidney and 19 Liver • 8 “Ineligible” Subjects • undiagnosed HIV, HIV RNA > 50 (K), low CD4, altered MS, history of OI/ON • Baseline CD4+ T Cell Counts Kidney: Liver: 455 (200 - 1054) 321 (103 - 973) • Baseline HIV-1 RNA Liver: <50 (<50 - 115,776) Results: Outcomes • Median follow-up 279 days (3 - 1567) • Deaths 1 kidney + 3 liver - recurrent hepatitis C - rejection after PI stopped - post-op complications x 2 • Opportunistic Complications 1 liver + 1 kidney - CMV esophagitis - candida esophagitis Results: Outcomes • CD4+ T Cell Counts Kidney Liver 460 (76 - 1300) 296 (89 - 590) • HIV-1 RNA Kidney Liver • Re-transplantation • Graft loss • Additional rejection < 50 (< 50 - 11,343) <50 (<50 - 80) 1 liver 1 kidney 36% kidney + 11% liver Outcomes: Ineligible Subjects • Undiagnosed HIV death (MAC< PML) • Altered MS death (PML) • HIV RNA > 50 (K) all <50 or < 400 • Low CD4 stable 76 --> 102 • History of OI/ON (PCP + CMV; KS + CMV) no recurrence at 15 months and 5 weeks Conclusions • Patient survival is comparable to UNOS data at 1 year 95% kidney subjects 84% liver subjects UNOS = 94.8% cadaver/97.6% living UNOS = 87.9% • No significant HIV disease progression in selected pts • 2 OI s could be due to HIV or immunosuppression • Stable CD4+ T-cell counts and suppressed HIV-1 RNA • There is HIV progression with advanced disease • Graft survival is comparable to UNOS data at 1 year 89% kidney subjects 84% liver subjects UNOS = 89.4% cadaver/94.5% living UNOS = 81.4%