Success With HIV-to-HIV Kidney Transplants

Three people living with HIV had promising outcomes after donating kidneys to three others with HIV, according to a prospective study within the HOPE in Action Multicenter Consortium.

Among the three living donors, grade 3 or higher nephrectomy-related adverse events occurred in two donors after donation, including a medically managed ileus and a laparoscopically repaired incisional hernia, reported Christine Durand, MD, of Johns Hopkins University School of Medicine in Baltimore, and colleagues.

Monitored glomerular filtration rate (mGFR) declined from 103 to 84 mL/min/1.73 m² at 4 years in donor 1, and estimated eGFR declined from 77 to 52 mL/min/1.73 m² at 3 years in donor 2, and from 65 to 39 mL/min/1.73 m² at 2 years in donor 3, they noted in the Lancet Regional Health-Americas.

These decreases were expected and did not indicate that the donors were at risk for chronic kidney disease or kidney failure, Durand and team said. HIV RNA remained <20 copies/mL and CD4 count remained stable in all donors, they added.

Donation of kidneys from people living with HIV is possible under the HIV Organ Policy Equity (HOPE) Act, enacted in 2013, which modified rules in the U.S. regarding organ donation and authorized clinical research among people with HIV.

Allowing organ transplantation between people with HIV increases the number of organs available for transplant, which benefits all those on transplant waiting lists, not just those living with HIV.

However, people with HIV are at increased risk of developing end-stage renal disease (ESRD). The authors noted that there had been concerns that a nephrectomy on a person living with HIV could increase that risk. The lifetime risk of ESRD in people living with HIV who become living donors remains unknown, the authors said. Among the three donors, the pre-donation 9-year estimated cumulative incidence of ESRD was 3.01, 8.01, and 7.76 per 10,000 persons, respectively.

"This new evidence is proof-of-concept that donating a kidney can be safe for people living with HIV," Durand said in a press release. "When added to the consistently positive outcomes documented for recipients of these organs, our study provides support that living donations from people with HIV to recipients with HIV can and do work."

In all three cases, the donated kidneys are still functioning. The first recipient needed to be hospitalized for infections three times. The second recipient was treated for rejection that was brought under control shortly after the transplant. The third recipient experienced ureteral leakage that required a nephrostomy tube and needed to be hospitalized for bleeding after a biopsy.

"It's gratifying to see that all three living donors are all doing well," David Klassen, MD, chief medical officer of the United Network for Organ Sharing, told MedPage Today. "Because of the limited number of cases, it remains important to continue careful evaluation and follow-up of these and future living donors."

"For the time being, these transplants will continue to be performed as part of research studies," added Klassen, who was not involved in the study. "It is unclear how many additional patients may benefit in the short term."

The donations were performed at Duke University, Johns Hopkins University, and Northwestern University, which are all part of the HOPE in Action Consortium and are approved to perform deceased donor kidney and liver transplants between people with HIV.

The three donors were Nina Martinez, age 35 at the time of donation; Karl Neumann, age 52 at donation; and Reed Benedict, age 47 at donation. They are listed as co-authors of the study.

Martinez originally planned to donate her kidney to a friend with ESRD, but he died before a transplant could be done. She ultimately decided on a non-directed donation to a person not known to her. Neumann also made a non-directed donation. Benedict donated his kidney to his husband, who was living with HIV and ESRD.

The three donors stated that they wanted to donate a kidney to help someone with ESRD who was undergoing dialysis and as a way to help reduce the stigma associated with HIV.

"Knowing the importance of organ donation, I was thrilled that the HOPE Act made it possible for me to become both a registered deceased organ donor and the nation's first living donor with HIV," says Martinez in the press release. "With the findings from our study and hopefully, those from research to come, another barrier to living donor HIV-to-HIV kidney transplants -- the concern that the donor's remaining kidney cannot function independently of the donated organ -- is being erased."

The donors were evaluated at 3 and 6 months after nephrectomy and then annually for 2 to 4 years. Under the study protocol, they were screened for active opportunistic infections, had an HIV RNA viral load of <50 copies/mL, and a CD4 T-cell count ≥500 cells/μL for the 6 months prior to donation.

They underwent a biopsy before donation that showed no disease process that could put the donor at increased risk of developing ESRD later or that would present a risk of poor graft function to the recipient. All three nephrectomies were performed laparoscopically.

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