4. You were offered kidneys from a 51-year-old male DBD (donor after brain stem death) donor who suffered from SAH (grade 5) complicating cerebral aneurysm. Her retrieval S Cr was 78 µmol/L. Virology was reported negative for both HBV and HCV, but HIV is positive.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
122 Comments
Mohammed Sobair
Will you accept this DBD donor?
Yes ,as per BTS guideline.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes ,HiV D+ to HIV +recipient. Is accepted.
Condition to be met.
Compliant to ART.
CD4 more than 200cell for 3months.
Viral copies less than 50 copies for 6months’
No history of opportunistic infection.
No proteinuria in donor or history of HIVAN.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Yes there no contraindication. with negatives FCM.
Follow up is needed
Q. 1, Will you accept this DBD donor?
Yes, I will accept the donation.
Q. 2,
Yes, I will accept, according literature demonstrated that this allograft can be accepted with HIV, if copies <50 and CD4+T >200 for more then six months.
However,
there is possibility of higher risk of rejection, secondary to drug toxicity,
and interaction. Q. 3,
There are certain criteria before to proceed for transplantation.
Like,
Donor should not have HIVAN.
May be biopsy necessary,
HIV copies should be <50.
CD4+ T cell should be >200cells/ul.
No opportunistic infection currently.
Recipient should be stable for at least 3 to 6 months.
No chronic infection, and malignancy. Q. 4,
There is no contraindication for transplantation
However, surveillance biopsy and follow up test mandatory.
Induction with basiliximab, maintenance medication with lower dose compare to others.
HIV-positive donor to HIV-positive recipient (HIV D+/R+) transplantation is permitted in the United States under the HIV Organ Policy Equity Act. To explore safety and the risk attributable to an HIV+ donor, we performed a prospective multicenter pilot study comparing HIV D+/R+ vs HIV-negative donor to HIV+ recipient (HIV D-/R+) kidney transplantation (KT) overall transplant and HIV outcomes were excellent; a trend toward higher rejection with D+ raises concerns that merit further investigation. https://pubmed.ncbi.nlm.nih.gov/32701209/
Will you accept this DBD donor? · Yes, I will accept this deceased donor (for HIV recipient) if donor’s kidney biopsy doesn’t show HIVAN. The donor should meet the following criteria: 1. The HIV viral load <50 copies/mL 2. The CD4 count >200/µL for at least 6 months before his brain injury 3. No evidence of proteinuria 4. No evidence of HIV-AN in preemptive kidney biopsy 5. No history of drug resistance or opportunistic infections · This recipient should receive proper counseling regarding the risk of transmission of other HIV strains and opportunistic infections before proceeding with transplantation. · Anti-retro-virals with significant drug interaction with tacrolimus should be changed prior to transplant. Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met? The HIV infected donor is unsuitable for living kidney donation as per BTS guidelines(2017).However, living kidney donation from HIV+ donor to HIV + recipient can be accepted as per HIV Organ Policy Equity Act 2013(HOPE 2013) if the donor and recipient full certain criteria: Donor criteria: · The HIV viral load <50 copies/mL · The CD4 count >200/µL for at least 6 months before his brain injury · No evidence of proteinuria · No evidence of HIV-AN in preemptive kidney biopsy · No history of drug resistance or opportunistic infections Recipient criteria: · Undetectable HIV viral load (< than 50 copies/ml for the 6 months prior to transplant. · stable CD4 count above 100 cells/ul during the 3 months before transplant · Expected life survival> 5 years. · Compliant on HAART. · No history of opportunistic infection for the 6 months before transplant. Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan? · I will accept this recipient with negative FCXM negative. The presence of DSA against A36 with low MFI 1550 carries low risk of hyper-acute rejection. There is no need for any desensitization prior to transplantation. · Immunosuppression: · Induction regimen: The IL-2 R anatagonist Basiliximab is preferred over the lymphocyte depleting agents like ATG and Almetuzumab in HIV positive recipients. Maintenance: Triple Immunosuppression :steroids+TAC +MMF. Post-transplant prophylaxis against PJP and CMV as per guidelines. Monitor drug levels, kidney function test., and DSA level. · Post-transplant prophylaxis for PJP and CMV is required. · Post-transplant monitoring of HIV RNA and CD4 count in the first month, then every 2-3 months till the end of the first year, then 3-6 monthly thereafter. · Post-transplant DSA follow up and possibly protocol-biopsy as per center protocol. References:
British Transplantation Society. Kidney and Pancreas Transplantation in patients with HIV, 2nd ed.; British Transplantation Society: Macclesfield, UK, 2017.
Kumar RN, Stosor V. Organ transplantation in persons with HIV. AIDS. 2020 Jul 1;34(8):1107-1116.
Muller E, Botha FCJ, Barday ZA, Manning K, Chin-Hong P, Stock P. Kidney Transplantation in HIV-positive Patients: Current Practice and Management Strategies. Transplantation. 2021;105(7):1492-1501
Blumberg EA, Rogers CC; American Society of Transplantation Infectious Diseases Community of Practice. Solid organ transplantation in the HIV-infected patient: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13499.
Sawinski D. Kidney Transplantation in Patients with HIV. Kidney360. 2020 May 6;1(7):705-711
Will you accept this DBD donor?
Yes I will accept him only for HIV infected recipient. After the introduction of ART, several studies have demonstrated comparable patient and graft outcomes between HIV-negative and HIV-positive kidney recipients.
Would you accept this donor as a live donor if the recipient is also HIV positive?
Yes I will. HIV-infected living donation was permitted under the HOPE Act., with a major concern regarding the safety of kidney donation in an HIV-infected person du e to risk of renal disease associated with HIV infection. For HIV infected recipient in the past there were higher rate of rejection which was multifactorial and includes the significant drug-drug interactions between CNIs and PIs or older generations of non-nucleotide reverse transcriptase inhibitors that can often lead to subtherapeutic level of immunosuppressive agents. recent advances in the HIV medications, especially after the introduction of the integrase inhibitors avoided this problem.
if yes, what are the conditions that should be met? -Donor must be under treatment for the last 6 months with Undetectable HIV viremia (< 50 copies/ml). CD4 more than 200 cells for at least six months. – a kidney biopsy must be done before TX to ensure absence if HIVAN. – both donor and recipient must continue and of HAART after transplant .
– no history of invasive infection, PCP, viral , or fungal meningitis. – Recipient must has CD4+ T cell counts are >100 cells/μL (ideally > 200 cells/ μL) and have been stable during the previous 3 months, HIV RNA has been undetectable during the previous 6 months, No opportunistic infections such as active CMV , no malignancy.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan? Negative FCXM is not a risk of rejection even in presence of DSA with MFI level not sufficient to cause positive crossmatch ( MFI 1550) so no contraindication for RX . Follow up of dsa and protocol biopsy early after TX is mandatory due to immune system dysregulation and he must be informed about potential risk of AMR.
It is better to avoid for induction reported case used Basiliximab induction and triple immune suppression maintenance.
Reference Ayelet Grupper12, Yaacov Goykhman12, Roni Baruch .In sickness and in health: Living HIV positive kidney donation from a wife to her husband, with 7 years’ post-transplant follow-up. 2019 Dec;21(6):e13171.
Yes, i would accept this DBD donor to increase donor pool & if following conditions are met
– HIV viral load <50 copies/ml and CD4 count >200/ul for at least 6 month prior to brain injury
– Information about the donor virus such as historical genotype patterns where possible and current viral load.
– No history of virological failure or drug resistance.
Recipient are councelled and give informed consent both at the time of listing and at the the time of transplantation
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Paients with HIV-infection are unsuitable to be living kidney donor.
I could accept this donor as a live donor if following conditions are met:
For Donor:
– No sepsis
– No active TB
– HIV RNA < 50 copies/ml.
– No proteinuria and exclusion of HIVAN
For Recipient:
– On antiviral treatmen for at least 3 month
– No detectable HIV RNA
– CD4>200/ul
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
– Induction therapy with basiliximab( NO ATG)
– Tacrolimus based tripple therapy
Scenario- HIV-positive donor with negative Hepatitis B and C
Will you accept this DBD donor?
No, unless the recipient is HIV positive
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes, however the recipient need to have
CD4 counts > 200
Suppressed viral load (HIV RNA)
Stable anti-viral regime
No active opportunistic infections or neoplasms
No history of chronic cryptosporidiosis
No history of primary CNS neoplasm or progressive multifocal leukoencephalopathy (1)
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
This patient has low-level HLA-DSA, careful assessment and explanation are important prior to donation (risk of hyperacute rejection)
Desensitization with IVIG and TPE
Basiliximab as induction instead of Thymoglobulin
Reference
Harbell J, Terrault NA, Stock P. Solid organ transplants in HIV-infected patients. Curr HIV/AIDS Rep. 2013 Sep;10(3):217-25. doi: 10.1007/s11904-013-0170-z. PMID: 23893004; PMCID: PMC5899895.
Q1: Yes, if the recipient is HIV positive, I will agree.
The HIV- negative recipients are not permitted to receive kidney from HIV-positive donors. The patient can donate kidney, if viral load is less than 50 and CD4 is above 200 during the last six-months. Negative history of drug resistance or genotype pattern are important to determine before donation.
The recipient should have no active infection or malignancy and be stable considering the above mentioned condition.
Q2: Yes, I will accept, if the donor’s kidney is not affected by HIV with no proteinuria and even normal kidney biopsy. The other conditions as mentioned above, should be met, as well.
Q3: I will proceed the transplantation, because FCXM is negative. DSA monitoring after TX should be performed.
In this situation, induction therapy with basiliximab should be considered and continue with the triple maintenance therapy. ATG is not logical, because of high risk of opportunistic infections.
Reference:
Blumberg, E. A., & Rogers, C. C. (2019). Solid organ transplantation in the HIV-infected patient: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clinical Transplantation, 33(9). https://doi.org/10.1111/ctr.13499
The donor is a deceased donor after brain death with good renal function….The donor is negative for HBV and HCV, but the donor is positive for HIV….
As per the HIV organ policy equity act permits HIV +ve donor to register as donors….They should be denied about their rights to donate their organs….The recipients as per the BTS guidelines in the HOPE act should be HIV positive…HIV positive organ donation to HIV negative recipients are not yet approved…
the donor should not have had history of virological resistance..The donor before donation should have a urine examination to rule out HIVAN
The other conditions that must be met before organ registration in HIV donors are that donor CD4 >200 and HIV RNA < 50 in last 6 out of 12 months…
So this organ can be given to HIV Positive recipient
Live donor with HIV positive status…
Personally It is best avoid kidney donation in donors with HIV.. due to the life long morbid nature of the disease…they are at risk of HIVAN and other complications due to the HAART and opportunistic infections…BTS recommends against kidney donation in HIV donors…If no other options are available for both donors and recipient they should be evaluated in detail
The donor and recipient should be on HAART and should have suppressed HIV Viral load in last 3 months….CD4 count >200 cells or atleast more than 100 cells in the last months…..
Both donor and recipient should be screened for HIVAN and if there is HIVAN in the donor the proceeding should be stopped….The donor and recipient should be screened for opportunistic infection namely latent TB as per NICE guidelines…They should not have history of lymphoma, PML or cryptosporidiosis…they both should not have history of HIV resistance….
If the potential recipient has DSA (A36 with MFI 1550), but a negative FCXM….. The low MFI value, the patient maybe taken up for transplant if all other donor and recipient criteria for HIV are met as mentioned above….We have use IL2 receptor antagonists as induction agent due to increased risk of infection and malignancy…standard maintenance.. with triple immunosuppression is needed ..Regular monitoring of DSA is recommended post transplant …We need to do renal biopsy if there is raising titres of DSA…We have to check CD4 count every month after transplant for 3 months and then monitor once in 3 months after renal transplant…Anti retrovirals should be given that have less enzymatic interaction and can be used post transplant….
No, donations for HIV D+/R- are not released yet, although there are feasibility studies for this situation.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
In this hypothetical situation, if the recipient is also positive, he would accept the organ. It would be necessary to fulfill the requirements of controlled viral load, CD4 > 200 copies and absence of opportunistic diseases
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
This DAS value is low, with no risk of acute rejection and no indication of stronger suppression induction.
Since there is no risk of acute hyperrejection, I would avoid induction with ATB and use corticosteroids with basiliximab and maintain the patient’s HIV ART treatment.
The donor with HIV can be accepted in transplantation when:
HIV RNA less than 50 copies and CD4 is more than 200 in the last 6 months prior to brain injury
No drug resistance Would you accept donor as live donor if recipient is also HIV positive? If yes what conditions should be met?
Yes, I will accept in case of:
HIV RNA is suppressed and CD4 more than 200
No infection
No HIV related nephropathy for the donor
If potential recipient has DSA(A36 with MFI 1550),but neg FCXM, what would be the mgt?
Low DSA level with low risk of rejection
Induction by basiliximab
Maintenance: CNI, MMF , steroid
1. Will you accept this DBD donor? Yes, HIV positive deceases donors are accepted, as per HOPE Act, after exclusion of HIVAN. Using organs from HIV-infected individuals is restricted to organs from deceased donors with: – HIV viral load <50 copies/mL and CD4 count >200/µL for at least 6 months prior to brain injury – Information about the donor virus such as historical genotype patterns where possible and current viral load – No history of virological failure or drug resistance Recipients are counselled and given informed consent about the donor serostatus, need for ART and monitoring. 2. Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met? As per BTS guideline · We recommend that patients with HIV-infection are unsuitable to be living kidney donors (1D) · We suggest that HIV+ organ use is restricted to those centres that have experience in transplanting HIV+ patients (Not graded) Although very few cases of HIV-to-HIV living donor transplantation are reported, personally, I would discourage organ donation from HIV-infected live donor, due to the high incidence of HIVAN and risk of CKD in HIV population, which might put them at higher risk of ESRD and death after kidney donation. If there is no alternate donor and the donor insists to donate to that particular HIV+ recipients, the following criteria have to be met:
Donor should not have proteinuria (+/- haematuria) and biopsy (if possible) to eliminate HIV associated nephropathy.
Both donor and recipient should have
no detectable viremia (or <50copies/ml) in last 3 months
CD4 >200Cells/UL in last 6 months
No h/of HIV-drug resistance
No h/o opportunistic infections, PML, Cryptosporidiosis or lymphoma – in both donor and recipient.
· Both donor and recipients should be screened for TB (Mx, IGRA/ QuantiFERON-TB Gold) LTBI and active TB, and if found, to have completed treatment as per NICE guidelines. · The potential donor should be assessed for HIV-RNA viral load, CD4+T-cell count and HCV coinfection, in addition to other conditions that preclude donation (DM, HTN, and pre-existing kidney disease) · HIV+ African American persons with apoprotein L1 (APOL1) genotypes are at high risk for the development of HIVAN and FSGS. · Post-kidney donation, HIV+ donors should avoid nephrotoxic ART (such as tenofovir), NSAID, other nephrotoxic drugs. 3. Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan? FCXM negative, DSA is positive, although not so high. · We have seen hyperacute rejections (in as many as 4 occasions) with such level of DSA (done on NGS- complete panel) in spite of T&B cell X match (both CDC and FCXM) negative. · HIV+ recipients being high immunological risk (30% risk of rejection), high DSA h would put the recipient at higher risk of rejection (especially ABMR). – So, I would prefer desensitization with 1 plasma exchange + IVIg 10 gram to minimize the risk of accelerated ABMR. · Induction Agent: T-cell depleting agent (Thymoglobulin) should be avoided in HIV positive recipients, although >30% of recipients in different studies have received Thymo-induction, without much complications (except lower CD4 cell count). · But this index case being high immunological risk, Thymoglobulin can be used, to prevent ACR. It will need frequent monitoring of CD4-Tcell count and surveillance for opportunistic infections. · Maintenance immunosuppression – triple drug regimen (Tacrolimus, Mycophenolate, and prednisone) as per guidelines to be used. · HAART needs to be continued immediately post-op after patient starts oral diet – Tenofovir should be replaced with other drugs. · Post-transplant, lifelong prophylaxis for pneumocystis jirovecii should be given. CMV prophylaxis for minimum 3 months for D+/R- pair and Toxoplasma prophylaxis if donor seropositivity should be given. · HIV RNA and CD4 count should be monitored at 1 month, and then every 2-3 months till 12 months, and then 3-6 monthly. · RFT and Tac C0 level needs to be monitored frequently, as CNI level fluctuate (may be low / very high) due to drug-interaction of ART with IS. Regarding induction agent – I would prefer Thymoglobulin, as the index case is candidate of high risk of rejection. Kidney transplant recipients with HIV have a high frequency of rejection. In a large, multicentre trial, 1and 3 years’ rejection rates were 31% and 41% respectively, compared to expected one-year rejection rate of 12%. There is a controversy regarding induction of IS – some use basiliximab (IL-2 RA) based on data from kidney transplant in recipients with HIV, that demonstrated an increased risk of infection among those treated with rATG-Thymoglobulin . Other centers prefer to use rATG-Thymoglobulin given its superior efficacy in preventing acute rejection in recipients without HIV. Post-transplant monitoring of DSA and a protocol biopsy at 3 months should be done. Presence of ABMR on biopsy, needs treatment with Plasma Exchange + IVIg (+/- Retuximab). If DSA is increasing, IS should not be reduced. If the DSA is not increasing, and there is no ABMR, then follow-up DSA level should be tested at 12 months and whenever there is any significant change in immunosuppression, graft dysfunction, or suspected non-adherence. References: 1. British Transplantation Society Guidelines 2017. Kidney & Pancreas Transplantation in Patients with HIV
2. Kumara N, Rebecca, Stosor V. Organ transplantation in persons with HIV. AIDS 2020, 34:1107–1116
Will you accept this DBD donor?
-Yes, HIV organ policy equity act permits HIV +VE donor to register as donors. The recipients will have to be HIIV +VE, Donation to HIV neg recipients is still frowned upon and not yet acceptable.
-Other conditions to be met that would give us better outcomes;
Donor CD4 > 200 and HIV RNA < 50 in last 6/12.
Donor with no hx of HIV resistance.
Would you accept donor as live donor if recipient is also HIV positive? If yes what conditions should be met? –Yes,I would accept.
-Conditions to be met;
Both to have suppressed HIV PCR levels in last 3/12.
Both to have CD4 >200Cells/UL in last 6/12.
Both to be screened for LTBI and active TB with tx as per NICE guidelines initiated.
Donor to have no proteinuria and a possible biopsy to eliminate HIV associated nephropathy.
No hx of HIV resistance in the pair.
Both to have no hx of PML, Cryptosporidiosis and lymphoma.
If potential recipient has DSA(A36 with MFI 1550),but neg FCXM, what would be the mgt?
Induce with basiliximab(IL2RA).Lymphocyte depleting agents avoided to have low risk of infections and malignancy.
Maintenance with ;CNI/antimetabolite/steroids.
Monitor DSA levels.
Lifelong PCP prophylaxis. CMV and Toxo prophylaxis to be given on individual case basis after evaluation of transplant pair.
Monitor CNI trough levels and carefully consider DI in choosing tx.
Monitor CD4 VL in 1/12 then every 2-3/12 in 1st year then 3-6/12.
REF; BTS guidelines 2017 – Kidney and pancreas transplantation in pts with HIV.
Will you accept this DBD donor?
· Transplantation using organs from HIV-infected individuals is restricted to organs from
deceased donors with:
a) HIV viral load <50 copies/mL and CD4 count >200/µL for at least 6 months prior to
brain injury
b) Information about the donor virus such as historical genotype patterns where
possible and current viral load
c) No history of virological failure or drug resistance
· Recipients are counselled and give informed consent both at the time of listing and at the time of transplantation
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
· Very few cases of HIV-to-HIV living donor transplantation are reported.
· The assessment of potential candidates for donor nephrectomy should include CD4+ cell count and HCV coinfection in addition to other conditions that preclude donation (e.g. DM, HTN, and preexisting kidney disease)
· HIV+ African American persons with high-risk apoprotein L1 (APOL1) genotypes are at risk for the development of HIVAN and FSGS.
· Post-nephrectomy, HIV+ donors should avoid nephrotoxic ART (such as tenofovir) in addition to agents such as nonsteroidal anti-inflammatory agents.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
· As MFI is not so high this patient does not need de-sensitization with is its risk of activation of the virus.
· ATG should be avoided, and Basiliximab is good choice for induction.
· Maintenance immunosuppressive regime may include Tacrolimus, Mycophenolate, and possible prednisone if the patient has high risk for rejection.
1) British Transplantation Society Guidelines. Kidney & Pancreas Transplantation in Patients with HIV
2)Organ transplantation in persons with HIV Rebecca N. Kumara and Valentina Stosor
Person with HIV can be accepted as donor ,specially after HOPE act
HIVAN has to be ruled out
for HIV positive recipient
if no opportunistic infection
CD4 more than 200/microL, viral copy less than 50 per ml – 6 months
no drug resistance
need to have viral genotype
should be in center regular with such transplants
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
yes we can accept kidneys from live donor
recipient criteria remains valid in this case as well
donor should have
no HIVAN
NO PROTEINURIA
NO HIV defining opportunistic infection
IN case of positive DSA AND negative FCXM-
Inducing agent like basiliximab is used and DSA need to be monitoring
ATG is associated with depletion of T cells and more chances of infection
Yes I will accept the donor but exclusion of HIVAN is must
Recommendations:
We recommend that transplantation using organs from HIV-infected individuals is restricted to organs from deceased donors with:
– HIV viral load <50 copies/mL and CD4 count >200/µL for at least 6 months prior to brain injury
– Information about the donor virus such as historical genotype patterns where possible and current viral load
– No history of virological failure or drug resistance (1D)
We recommend that recipients are counselled and give informed consent both at the time of listing and at the time of transplantation (1D)
We suggest that HIV+ organ use is restricted to those centres that have experience in transplanting HIV+ patients (Not graded)
We recommend that patients with HIV-infection are unsuitable to be living kidney donors (1D)
———————
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes, we should to exclude donor HIVAN by kidney biopsy
the general consensus is that the recipient should have
a CD4 count >200 cells/µL,
an HIV viral load <50 HIV-1 RNA copies/mL, demonstrate adherence and tolerance to HAART, and be absent of AIDS-defining illnesses.
British and Italian groups exclude patients with prior or current infections that are considered to be high risk for reactivation with immune suppression .These infections include aspergillosis, other invasive fungal infections, active cytomegalovirus, recent influenza, recent RSV, recent severe bacterial infection, or incompletely treated mycobacterial infection.
No protienuria
No HIVAN
The HOPE Act also allows people with HIV to be living donor to HIV infected recipient To become an HIV-positive living donor, you must:
Meet all requirements of the transplant center
Have an undetectable viral load and a CD4 count over 500
Have no prior history of an invasive infection, such as PCP pneumonia or active fungal meningitis
Undergo a kidney biopsy
—————————————-
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
induction therapy with basiliximab and monitoring of DSA
This donor can be accepted if both the deceased donor and recipient fulfill criteria for transplantation.
– Recipient is counseled regarding risk of getting HIV infection and information about the DD HIV condition.
-Criteria for DD:
HIV viral load< 50 copies/ml & CD count >200/Ul for at least 6 months before brain injury.
No HIVAN proved by biopsy and no proteinuria.
If donor is a live donor & recipient is also HIV positive?
Donor can be accepted, if the recipient meets the criteria:
HIV viral load< 50 copies/ml & CD count >200/Ul for at least 6 months before brain injury.
No HIVAN proved by biopsy and no proteinuria.
No opportunistic infection.
If potential recipient with DSA (A36 with MFI 1550), & negative FCXM:
Transplantation can be performed with basiliximab as induction therapy.
Maintenance IS: MMF, CNI, & steroid,
Prophylaxes against CMV and PCP.
Monitoring drug-drug interaction
..Protocol biopsy.
Monitoring HIV RNA and CD4 count /2-3 months for the first year.
In the current scenario of positive HIV potential deceased donor to negative HIV recipient:
It is contraindicated.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met.
HIV-positive donor to HIV positive recipient can be accepted with preconditions in the recipient:
-Un undetectable viral load
-CD4 count >200
-It was traditionally considered an absolute contraindication for transplantation because of the concern that immunosuppression would accelerate HIV disease progression, resulting in increased mortality and a “waste” of organs. Currently in view of potent antiretroviral therapy (HAART) became widely available in 1996, the prognosis of patients with HIV infection has dramatically improved.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
-Regarding induction immunosuppression will proceed as a high risk of rejection.
Kidney transplant recipients with HIV have a high frequency of rejection. In a large, multicenter trial, one-and three-year rejection rates were 31 and 41 percent, respectively, compared with an expected one-year rejection rate of 12 percent.
There is a controversy regarding induction of IS some use basiliximab (an IL-2 receptor antibody) based upon data from two studies of kidney transplant recipients with HIV that demonstrated an increased risk of infection among those treated with rATG-Thymoglobulin . Other centers prefer to use rATG-Thymoglobulin given its superior efficacy in preventing acute rejection in recipients without HIV.
Will accept this donor to the positive HIV recipient if the viral HIV RNA is less than 50 copies/ml and CD4 count of more than 200.
Donors with HIV need to have normal kidneys with no proteinuria or elements of HIVAN.
The donor should be on HAART TREATMENT WITH no evidence of resistance.
The transplant will be to a positive HIV recipient with a CD4 count of more than 100
and should be stable for the last three months with undetectable HIV RNA , with no opportunistic infection.and no MLP
HIV viral load <50 copies/mL and CD4 count >200/μL for at least 6 months prior to
brain injury
Information about the donor virus such as historical genotype patterns where possible and current viral load
No history of virological failure or drug resistance.
b- Recipient: is HIV positive and :
compliant to previous antiviral treatment
Their CD4+ T cell counts are >100 cells/μL (ideally > 200 cells/ μL) and have been
stable during the previous 3 months (1B)
HIV RNA has been undetectable during the previous 6 months (1B)
No opportunistic infections have occurred during the previous 6 months (1B)
no history of progressive multifocal leukoencephalopathy, chronic
intestinal cryptosporidiosis, or lymphoma.
2- We can accept as a live donor:
after evaluating the donor for identification HIV-specific risk factors for development of ESRD such as low CD4+ cell count and HCV co-infection in addition to other conditions that generally exclude persons from donation (e.g. diabetes mellitus, hypertension, and preexisting kidney disease). Very few cases of HIV-to-HIV living donor transplantation have been reported in the literature.
3- If patient has DSA (A36 with MFI 1550):
the DSA is not so high
we can use basiliximab as induction therapy. as ATG associated with increase risk of bacterial infection and graft loss
consider use of IVIG
Maintenance: triple therapy tacrolimus, MMF and steroid
You were offered kidneys from a 51-year-old male DBD (donor after brain stem death) donor who suffered from SAH (grade 5) complicating cerebral aneurysm. Her retrieval S Cr was 78 µmol/L. Virology was reported negative for both HBV and HCV, but HIV is positive. Will you accept this DBD donor?
-Yes, HIV organ policy equity act permits HIV +VE donor to register as donors. The recipients will have to be HIIV +VE, Donation to HIV neg recipients is still frowned upon and not yet acceptable.
-Other conditions to be met that would give us better outcomes;
Donor CD4 > 200 and HIV RNA < 50 in last 6/12.
Donor with no hx of HIV resistance.
Would you accept donor as live donor if recipient is also HIV positive? If yes what conditions should be met?
–Yes,I would accept.
-Conditions to be met;
Both to have suppressed HIV PCR levels in last 3/12.
Both to have CD4 >200Cells/UL in last 6/12.
Both to be screened for LTBI and active TB with tx as per NICE guidelines initiated.
Donor to have no proteinuria and a possible biopsy to eliminate HIV associated nephropathy.
No hx of HIV resistance in the pair.
Both to have no hx of PML, Cryptosporidiosis and lymphoma.
If potential recipient has DSA(A36 with MFI 1550),but neg FCXM, what would be the mgt?
Induce with basiliximab(IL2RA).Lymphocyte depleting agents avoided to have low risk of infections and malignancy.
Maintenance with ;CNI/antimetabolite/steroids.
Monitor DSA levels.
Lifelong PCP prophylaxis. CMV and Toxo prophylaxis to be given on individual case basis after evaluation of transplant pair.
Monitor CNI trough levels and carefully consider DI in choosing tx.
Monitor CD4 VL in 1/12 then every 2-3/12 in 1st year then 3-6/12.
REF;
Prof Ahmed Halawa lecture.
BTS guidelines 2017 – Kidney and pancreas transplantation in pts with HIV.
4. You were offered kidneys from a 51-year-old male DBD (donor after brain stem death) donor who suffered from SAH (grade 5) complicating cerebral aneurysm. Her retrieval S Cr was 78 µmol/L. Virology was reported negative for both HBV and HCV, but HIV is positive.
– virology screen: HBV negative, HCV negative, HIV positive
Will you accept this DBD donor?
– yes, I would accept the DBD donor, as long as the potential recipient is HIV positive as well
– with the HOPE Act i.e., HIV Organ Policy Equity Act, HIV positive patients can now register as organ donors
– however, intentional transplantation of HIV positive organs to HIV negative recipients is still not an acceptable practice due to medical and ethical concerns
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met? (1)
– yes, I would accept him as a live donor – the HOPE Act permits HIV-positive living donation
– the recipient should be made aware of the potential risks and benefits of receiving HIV positive organ for transplant
– the potential donor must undergo a kidney biopsy prior to kidney donation
– there are a couple of concerns when dealing with HIV positive donors e.g.,
potential consequences of the superinfection with the donor’s HIV strain
risk of transmission of OIs (latent or unrecognized) to the recipient
poor organ quality due to prevalent hepatic, kidney and cardiac diseases in the HIV positive population
– some conditions to be met prior to transplantation, these include:
prior to donation, the following data about the HIV positive donor should be made available: – CD4, viral load, HIV genotypic testing, HAART history, history of OIs
assess for HIV-specific risk factors for development of ESKD in the donor e.g., low CD4, HCV co-infection, diabetes, hypertension
screen for any pre-existing kidney disease including HIVAN in the potential HIV positive donor UECs, urinalysis, abdominopelvic ultrasound, kidney biopsy
– transplant requirements for both the donor and the recipient include: –
CD4 >200 for the last 6months
undetectable HIV viremia for the last 6months
compliance to HAART
absence of opportunistic infections for the last 6months
absence of HIV-associated malignancies
absence of chronic wasting or severe malnutrition
access to immunosuppressive agent therapeutic drug monitoring (for recipient)
availability of regular clinic follow-up for the HIV infection
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan? (1)
– multidisciplinary approach: HIV specialist, it is prudent to discuss the HAART regimen before transplantation due to the anticipated DDIs, also avoid nephrotoxic agents post-transplant
– history: current HAART regimen, OI history, any malignancies, compliance
– baseline investigations: CBC, UECs, LFTs, urinalysis, HbA1c, lipid profile, CD4, viral load, sputum gene xpert, HBV, HCV, HEV, chest radiograph, screen for OIs, malignancy screen
– immunosuppressive regimens should be individualized based on the immunologic risk, HAART regimen, liver function
– induction regimen:
ATG or Basiliximab – ATG has been associated with prolonged lymphocyte depletion, more frequent and severe infection compared to Basiliximab
some studies reported lower rejection and infection rates with ATG, hence the need for individualized treatment
in this patient with DSA (A36 with MFI 1550) negative FCXM, I would induce with Basiliximab
– maintenance regimen:
tacrolimus is the preferred CNI since it is associated with lower rejection rates; CNIs decrease HIV-1 DNA transcription
mycophenolate is the commonly used antimetabolite
long-term prednisone use reduces the risk of rejection but one should weigh the benefits against the long-term effects of prednisone use
sirolimus has anti-HIV effects via upregulation of ß-chemokines, downregulation of CCR5 and blockade of mTOR; sirolimus also decreases the HIV reservoir
I would maintain this patient on a tacrolimus-based triple therapy regimen i.e., tacrolimus, mycophenolate and prednisone
– the best induction and maintenance immunosuppressive regimens are yet to be determined
– adequate trough levels should be maintained to avoid rejection
– drug-drug interactions (DDIs) do occur between HAART and the immunosuppressive agents
– DDIs can result in inconsistent immunosuppressive drug levels hence increasing the risk of rejection (in the case of sub-therapeutic drug levels) or risk of toxicity (in the case of supra-therapeutic drug levels)
– PIs are cytochrome P450 3A4 (CYP3A4) enzyme inhibitors whereas NNRTIs are enzyme inducers
– PIs are associated with poor outcomes (i.e., graft loss/ rejection and mortality) compared to non-PI based regimens
– non-boosted integrase strand transfer inhibitors (INSTI) are now a favourable option
– CD4 and HIV viral load should be monitored closely in the following case scenarios: – early post-transplant period, during graft rejection and when the immunosuppressive regimen is adjusted
– monitor CD4 and viral load at one month then every 3 months post-transplant
– offer the usual post-transplant prophylaxis against PJP, CMV, fungal infection, LTBI
References
1. Kumar RN, Stosor V. Organ transplantation in persons with HIV. AIDS (London, England). 2020 Jul 1;34(8):1107-16. PubMed PMID: 32167973. Epub 2020/03/14. eng.
British Transplantation Society Guidelines – Kidney & Pancreas Transplantation in Patients with HIV
Donor virology reveals negative for HBV and HCV but positive for HIV.
I would not accept this donor if the recipient is HIV negative/naive.
I would accept this donor if the following conditions are met :
Recipient is also HIV positive
Donor has no history of resistance to ART
CD4 count of the donor should be more than 200 cells/microlitre and HIV RNA less than 50 copies/mL on ART in the previous 6 months.
Live donor, recipient, both HIV positive
Yes, I would accept live donor if the recipient is also HIV positive.
The conditions to be met are as follows :
The recipient and the donor must have CD4 count above 200 and undetectable viral load to be considered for the transplant.
Low viral load maintenance is important to achieving good outcome post transplant.
The donor must have no previous history of an invasive infection, like PCP pneumonia or active fungal meningitis
Kidney biopsy must be done for the donor to check for HIVAN
Donor has no proteinuria or hematuria on urine examination since this could be a risk factor for development of HIVAN post transplant in the recipient.
Donor must not have an active current infection that is a high risk for reactivation with immune suppression
Donor must have history of adherence to ART
Donor must not have any AIDS defining illness
Recipient DSA+, negative FCXM
Since the recipient is DSA positive A36 with MFI 1550, with negative FCXM, the following would be part of the management plan :
Induction therapy – Basiliximab instead of ATG since the latter can worsen infection and increase risk of malignancy in HIV patients. Basiliximab is a better choice in this case. KDIGO guidelines recommend
It is important to check when the patient received ART following the initial diagnosis, since late administration of ART has been linked to development of HIVAN in HIV recipients. In this case, the recipient would have to be closely monitored post transplant for proteinuria, hematuria and any other symptoms for HIVAN. However, it is also important to remember that HIVAN can occur with no proteinuria with good graft function.
Maintenance therapy would include triple IS regimen with MMF, tacrolimus and prednisolone.
ART therapy may have to be adjusted according to IS regimen.
DSA levels have to be carefully monitored to decrease risk of graft rejection.
Frequent and close monitoring is crucial for trough levels of tacrolimus since it can be affected by ART and may lead to over immunosuppression increasing risk of infection and malignancy, or under immunosuppression raising the risk of graft rejection and unsuccessful outcome for the transplant.
References
Alameddine M, Jue J, et al. Challenges of kidney transplantation in HIV positive recipients. Transpl Androl Urol, 2019; 8(2) : 148-154. doi: 10.21037/tau.2018.11.09
Zheng, X., Gong, L., Xue, W. et al. Kidney transplant outcomes in HIV-positive patients: a systematic review and meta-analysis. AIDS Res Ther 16, 37 (2019). https://doi.org/10.1186/s12981-019-0253-z
Kucirka L, Durand C, et al. Induction immunosuppression and clinical outcomes in HIV infected kidney transplant recipients. Am J Transplant. 2016; 16(8) : 2368-2376. doi: 10.1111/ajt.13840
Muller E, Botha F, Barday Z, et al. Kidney Transplantation in HIV positive patients : current practice and management strategies. Transplantation. 2021; 105(7) : 1492-1501. doi: 10.1097/TP.0000000000003485
Will you accept this DBD donor?
Donor with negative HBV and HCV but positive HIV.
Yes I would accept this donor instead of wastage of the organs.
The recipient should however be counselled on the risk of infection and consent obtained.
Further conditions to be met should include:
The donor CD4 count >200cells/ul and HIV RNA <50 copies in the prior 6 months.
The donor should have no history of virological failure and HIV resistance.
The donor should have no proteinuria and a graft biopsy may be done to rule out HIVAN
The recipient should also be HIV positive.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
If both donor and recipient are HIV positive, yes I would accept living donation.
Conditions to be met include:
Both donor and recipient should have undetectable HIV PCR for the past 3 months.
The recipient and donor CD4 count should be above 200cells/ul for the past 6 months.
They both should not have a history of prior PML, lymphoma, intestinal cryptosporidiasis.
The donor and recipient should be screened for latent and active TB and if positive be treated prior to transplantation.
The recipient should be compliant on the cART.
Both donor and recipient should not have an opportunistic infection and active malignancy.
The donor urine should be free of protein and a kidney biopsy should be done to rule out HIVAN.
Both donor and recipient should not have HIV multi drug resistance.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
FCXM negative with positive DSA the induction therapy should thus be with IL2RA- basiliximab.
Lymphocyte depleting agents should be avoided due to high risk of infections and malignancy.
Maintenance therapy should be triple therapy with CNI+mycophenolate+ steroids.
The antiretroviral with minimal drug interactions should be chosen prior to transplantation ideally integrate inhibitors and NRTI.
HIV virological monitoring should be done frequently, in the first month then every 2-3 months for the first year then every 3-6 months thereafter.
Recipient should be placed on lifelong PCP prophylaxis.
Other prophylaxis to be considered include CMV, toxoplasmosis, MAC,TB.
Frequent monitoring of the CNI trough levels.
References
Kidney & Pancreas Transplantation in Patients with HIV Second Edition
Compiled by a Working Party of The British Transplantation Society March 2015
[Minor Revision January 2017]
British Transplantation Society Guidelines
yes, I will utilize this kidney if an undetected viral load <50 copies last 6 months, CD4 count >100 (ideally >200), no hx of cART failure, no hx of progressive multifocal leukoencephalopathy, lymphoma, or intestinalcryptosporidiosis.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
>Yes, with the same previous measures in the recipient in addition to the need for exclusion of HIVAN by hx, proteinuria assessment, & biopsy.
>regarding the donor, it is better to be of low immunological risk, so induction with basiliximab will be better with the same precaution regarding HIV viral load ,CD4 count , hx of opportunistic infection & hx of progressive multifocal leukoencephalopathy, lymphoma, or intestinal cryptosporidiosis. > prophylaxis post-transplant for CMV, PCP, and toxoplasmosis, monitor closely for HIV PCR, CD4 count (every 2-3 months at 1st year), drug-drug interactions, proteinuria, and graft function.
>protocol biopsy may be considered.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
induction with basiliximab
maintainace with steroid+tacrolimus+MMF
monitor DSA levels
Will you accept this DBD donor? yes, if the deceased donor and recipient full fill the criteria to proceed with transplantation, donnor HIV viral load< 50 copies/ml and CD count >200/ul for at least 6 months prior to brain injury.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
yes if the receipt meet criteria of low viral load and high CD count with no opportunistic infections or malignancies.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
FCXM is negative transplantation can proceed
Basiliximab can be used as induction therapy. CNI, MMF and steroid as mantiance and monitor drug-drug interaction using the liverpool tool.
Monitor the HIV RNA and CD4 count frequently in the first year
Yes I will accept if fulfill criteria :
1.Patients demonstrate overall concordance with recommended treatment, and with cART therapy in particular .
2. CD4+ T cell levels are a minimum of 100 cells/µL and ideally >200 cells/µL and have been stable during the last 3 months .
3. HIV RNA has been undetectable during the last 3 months .
4.No opportunistic infections have occurred during the last 6 months .
5. No history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma .
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Many centres of transplantations take a postive HIV donor as contraindication .but I will accept ,after doing donor genotypic testing to confirm lack of resistance , the recipient should be counselled about the risk of transmission of viral resistance. Preimplantation biopsies may be considered to detect donor disease(HIVAN) .
The risk of recipient super-infection, recombinant virus or virus from a different clade, loss of virological control or transmission of viral resistance.
Transplantation may offer the outcomes at 3 to 5 years. Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
low titer DSA, but negative flow cross match, this is moderate transplant.
However since the recipient is HIV positive so risk of infections is high, so avoiding ATG will be wise decision .
basiliximab instead with standard triple immunosuppression.
Monitoring the DSA . References
1. Kumar MS, Sierka DR, Damask AM, et al. Safety and success of kidney transplantation and concomitant immunosuppression in HIV-positive patients. Kidney Int 2005; 67: 1622-9.
2. Swanson SJ, Kirk AD, Ko CW, et al. Impact of HIV seropositivity on graft and patient survival after cadaveric renal transplantation in the United States in the pre highly active antiretroviral therapy (HAART) era: an historical cohort analysis of the United States Renal Data System. Transpl Infect Dis 2002; 4: 144-7.
3. Muller E, Kahn D, Mendelson M. Renal transplantation between HIV-positive donors and recipients. N Engl J Med 2010; 362: 2336-7.
4. Hilton R. Human immunodeficiency virus infection and kidney disease. J R Coll Physicians Edinb 2013; 43: 236-9.
5. 2-BTS guidelines 2015
Will you accept this DBD donor?
No, I will not accept this donor untill, I have HIV viral load status as per the inclusion criteria and HIVAN is ruled out.
Personally I feel that there cannot be any emergency for a CKD patient on maintainance dialysis that he has to be given an infected organ when he himself is HIV negative and that to from DBD donor where many other factor responsible for decreased graft survival come in to play as compared to live donor.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met.
Yes, I will accept this donor if following criteria are met.
Recipient is on regular, compliant cART therapy.
Their CD4+ T cell counts are >100 cells/ML (ideally > 200 cells/ ML) and have been stable during the previous 3 months.
HIV RNA has been undetectable or fully suppressed (< 50 copies/ml) for over 6 months
No history of opportunistic infections over last 6 months
No history of PML or lymphoma
Donor also fulfils the HIV RNA load criteria
HIVAN is ruled out in donor kidneys
Donor doesnt have any opportunistic infection
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
No, I will not accept this kidney. There is currently insufficient data available to confidently comment that DSA positive FCXM negative recipient has favourable long term outcome.
The literature available states that it has acceptable outcome in short term. But when there is already an added risk factor of HIV positivity, I will refrain from taking bthis risk.
REF:
BTS guidelines
Buttigieg J, Ali H, Sharma A, Halawa A. Positive Luminex and negative flow cytometry in kidney transplantation: a systematic review and meta-analysis. Nephrol Dial Transplant. 2019 Nov 1;34(11):1950-1960. doi: 10.1093/ndt/gfy349. PMID: 30508114.
HIV-infected organs should only be transplanted from deceased donors with no HIVAN, if the recipient is also HIV positive and the following criteria are met by the recipent: Has undetectable HIV RNA for last 6 months, CD4 count ideally >200/μL for more than 3 months, absence of opportunistic infection in last 6 months, and no history of lymphoma, cryptosporidiosis, and progressive multifocal leukoencephalopathy.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes, if the recipient is also HIV positive transplantation can be done provided the following conditions are met:
Donor Criteria:
HIV <50 copies/mL and CD4 count >200/μL.
No history of opportunistic infections in the last 6 months.
No history of resistance to anti-retroviral medication.
The donor kidney is free from HIV associated nephropathy as assessed by necessary investigations such as urine exam to exclude proteinuria/ hematuria, and if needed, a pre-transplant kidney biopsy to rule out HIV associated nephropathy (HIVAN) should be done.
The recipient should be counseled about the risk of transmission of HIV, opportunistic infections, and resistance anti-retroviral medication prior to transplantation.
have undetectable HIV RNA for last 6 months,
CD4 count >200/μL for more than 3 months
No opportunistic infection in last 6 months
No history of lymphoma, cryptosporidiosis, or progressive multifocal leukoencephalopathy.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Antiretroviral regimens that have minimum medication interactions with CNI should be chosen prior to transplantation.
Basiliximab is preferred over ATG as induction agent in HIV-positive patients.
Maintenance immunosuppression consisting of steroids, a CNI, and MMF may be given.
After transplant, prophylaxis for Pneumocystis jirovecii, CMV and Toxoplasma should be started.
HIV RNA and CD4 count should be monitored at 1 month, and then every 2-3 months till 12 months, and then 3-6 monthly.
Post-transplant monitoring of DSA and a protocol biopsy at 3 months has to be done. If acute rejection develops (rise of DSA) plasma-pheresis may be done. The immunosuppression should not be reduced.
yes, if the deceased donor and recipient full fill the criteria to proceed with transplantation.
the recipient should be counseled about the risk of getting HIV infection and the outcome and the not to disclosure this information about the DD HIV status
criteria for DD to be met:
HIV viral load< 50 copies/ml and cd count >200/ul for at least 6 months prior to brain injury.
exclude HIVAN by biopsy and absence of proteinuria
the recipient should be fit and not contraindicated for transplantation.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
yes, the recipient will meet the criteria:
HIV viral load< 50 copies/ml and cd count >200/ul for at least 6 months prior to brain injury.
exclude HIVAN by biopsy and absence of proteinuria
absence of opportunistic infection.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
FCXM is negative transplantation can proceed and basiliximab can be used as induction therapy.
maintenance IS include MMF, CNI, and steroid,
monitoring the drug-drug interaction between CNI and cART medication.
prophylaxes to CMV and PCP should be considered,
based on the center protocol the protocol biopsy can be done.
monitor the HIV RNA and CD4 count every 2-3 months in the first year
Yes, I will accept this deceased HIV known donor patient .This can be donated to HIV positive recipient. Provided that there is proper patient centered counselling and consent.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes this can be approved provided that certain conditions ought to be met for both the donor and the recipient.
Regarding the recipient; preferred to be fit, adherent to HIV medications (c ART therapy), their CD4 count is acceptable (between 100 to 200 cells /ul at least), with stable clinical condition for the last 3 months, with undetectable HIV RNA for at least 6 months, history must be free from any opportunistic infections the previous 6 months, no history suggestive ofProgressive multifocal leukoencephalopathy (PML), having proper vaccination protocol.
Regarding the living donor, it is preferred to be better matched especially DR loci, with proper counselling with the expected risk for development of CKD or HIVAN. Besides the previously explained recipient conditions regarding clinical and laboratory assessment.
The donor should be aware of the necessary follow up post donation for HIV status, renal profile with special attention to development of proteinuria or any associated comorbid conditions.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Transplantation can be performed as long as FCXM is negative, however precautions are to be taken in consideration with immunosuppression induction (basiliximab is fine for induction) along with triple immunosuppressive regimen preferred to be tacrolimus based besides steroids and MMF. Another important alert to the drug level with other c ART therapy and proper dosing to avoid expected drug interactions. Prophylaxis against CMV, PCP, and other opportunistic infections is to be extended preferably according to patient status. Meticulous follow up for DSA levels, protocol biopsies are to be performed based on the centre’s protocol. Follow up HIV RNA levels and CD4 count on frequent basis is crucial particularly in the first year.
Yes, a donor with HIV can be accepted to expand the donor with certain criteria to minimize the risk to recipient. He can donate a kidney to someone who is HIV positive. On November 21, 2013, the HOPE Act (HIV Organ Policy Equity Act) was signed into law. This law allows people with HIV to register as organ donors. People with HIV on the transplant wait list at approved centers can choose to accept these organs. (In other words, organs from HIV-positive donors are only offered to HIV-positive transplant candidates.) The transplant center will look at the deceased donor’s CD4 counts and HIV viral loads, but there is no absolute threshold for either. Some centers. BTS guidelines recommend: Transplantation using organs from HIV-infected individuals is restricted to organs from deceased donors with:
a) HIV viral load <50 copies/mL and CD4 count >200/μL for at least 6 months prior to
brain injury.
b) Information about the donor virus such as historical genotype patterns where
possible and current viral load.
c) No history of virological failure or drug resistance.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
To be considered a living donor, he should meet certain criteria:
1-CD4 count>500/microL for last 6 months.
2-HIV RNA <50 copies/ml.
3-No invasive opportunistic complications of HIV. They should undergo a pre-implantation biopsy. Donor should undergo all routine pre donation workup.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Having low titer DSA, but with negative flow crossmatch, puts him at moderate transplant. However since the recipient is HIV positive so risk of infections is high, so avoiding ATG will be wise decision and give basiliximab instead with standard triple immunosuppression. Monitoring the DSA is important in such case.
References:
1-Transl An Challenges of kidney transplantation in HIV positive recipients Mahmoud Alameddine1, Joshua S. Jue2, Ian Zheng1, Gaetano Ciancio 2-BTS guidelines 2015
The current donor is negative for HBV and HCV but he is HIV positive.
This donor can be accepted for HIV positive recipient only as long as donor’s kidney biopsy doesn’t show HIV-AN.
This donor should have the following criteria before donation:
1- HIV viral load below 50 copies/ml for at least 6 months before head njury.
2- CD4 above 200/ul for at least 6 months before head injury.
3- No history of virological failure or drug resistance.
4- No evidence of HIV-AN by kidney biopsy.
5- No evidence of proteinuria.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
According to BTS guidelines 2017; patients with HIV infection are deemed unsuitable for living kidney donation.
I would accept this HIV positive donor as a living donor to HIV positive recipient if the following criteria are fulfilled as per HIV Organ Policy Equity Act 2013(HOPE 2013):
1- Undetectable viral load (less than 50 copies/ml) for the last 6 months.
2- CD4 above 200 for the last 6 months.
3- No history of invasive infection like PJP, fungal meningitis.
4- No evidence of HIV-AN by kidney biopsy.
5- No evidence of proteinuria.
6- Fulfilling all requirement by the transplant center.
On the other hand, the recipient should fulfill the following criteria as well:
1- Expected life survival above 5 years.
2- Compliant on HAART.
3- CD4 count above 100 cells/ul and being stable during the last 3 months.
4- Undetectable HIV viral load (less than 50 copies/ml for the last 6 months.
5- No history of opportunistic infection for the last 6 months.
6- No history of PML, Cryptosporidiosis or lymphoma.
· Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Presence of DSA with negative flowcytometry cross-match makes the donation offer acceptable especially DSA is against A36 with MFI 1550 (not a high titer) with low risk of hyper-acute rejection. No need for desensitization before renal transplantation.
Pre-transplant vaccination as per guidelines in HIV patients. Induction regimen: Basiliximab (IL-2 R anatagonist), avoid ATG and Almetuzumab in HIV positive recipients. Maintenance: Triple IS (Tacrolimus+steroids+MMF). Post-transplant prophylaxis against PJP and CMV as per guidelines. Monitor drug levels, kidney function test., and DSA level.
References:
1- National Kidney foundation. HIV and Kidney Transplantation/Donation.
2- BTS kidney and pancreas transplantation in patients with HIV-2017.
3- Kidney & Pancreas Transplantation in Patients with HIV Compiled by a Working Party of The British Transplantation Society March 2015.
Yes I will accept if the recipient is HIV positive or recipient negative but should be written consent and counselling regarding risk of transmission.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes if both are positive but should met criteria of HIV viral load is less than 50 copies and T CD 4 more than 200 and no evidence of opportunities infection and treatment by HAAT
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
So should treat by basiliximab as induction therapy and maintenance by tacrolimus/ MMF and steroid
⭐ yes, I will accept this donor (but only for HIV postive recipient ) with the following precautions: _Donor has negative HIV PCR less than 50 copies /ml and CD4 cell count > 200 cells /ml in preceding 6 months prior to death, in addition to absent history of ART resistance or non adherence or history of active opportunistic infection.
_exclusion of HIVAN in the donor by urine analysis (exclude hematuria and protinuria ), also by biopsy
_The recipient must be HIV postive with control of infection, adherence to ART and CD4 cell count > 200, HIV PCR negative, bo active opportunistic infection or malignancy .
⭐ ⭐ living donation from HIV donor is still just in few case series .
_If it is used , only for HIV postive recipient.
_Obtain consent from both donor and recipient .
_only after counseling the donor about risk of donation and avoid nephrotoxic ART as tenofovir after nephrectomy.
_Recipient should have close follow up of graft function.
_close follow up of HIV control (HIV PCR, cd4 cell count).
_cloae follow up of trough level (avoid protease inhibitors nad better use of integrase inhibitors ) to minimized drug-drug interactions with CNI
👉 👉 As long as FCXM is negative, proceed with Tx after prerequisites of HIV recipient ….induction with basiliximab and use of TAC based triple therapy to prevent AR (as DSA is postive ).
_ close follow up of DSA titre and protocol biopsy to detect subclinical rejection.
_treatment of ABMR is indicated based on biopsy (not only presence of DSA).
_treatment as HIV naive (PEX, IVIG and rituximab).
_close monitoring of trough level of CNI (avoid protease inhibitors ART and use of integrase inhibitors)
_ use of prophylaxis against PJP and CMV as HIV naive.
👉👉sure, exclusion of HIVAN in the living donor is more crucial than in deceased one for the sake of both the donor and recipient.
_HIVAN in the donor carries a risk of his progression to ESKD and precludes donation. In addition, it indicates either late initiation or non adherence to ART so all against accepting donation.
_For the recipient, it has risk of allograft failure and poor patient and graft outcome
1-In the last decades, the utilization of HIV-positive patients has grown. In 2003 started with D-/R+ followed by D+/R+ and lastly D+/R-. We need to discuss this with the recipients and take their consent and then we can accept if eligibility criteria are available. anti-HIV positive patients can donate if viral load is low az <50 copies with CD4>200 and clinical stability of at least 6 months.
2-HIV-positive to positive donation can be done but we need to fulfil the criteria regarding the recipient: compliance with cART therapy, CD4+ T cell count >100 (preferably more than 200) with stable clinical picture free of opportunistic infections at least for 6 months and no history of HIV associated nephropathy, PML etc.
3- As low-risk, we can use non-depleting agents lide Basiliximab, followed by triple IS maintenance. (TAC/MMF/steroid)
————-
**Botha J, Fabian J, Etheredge H, Conradie F, Tiemessen CT. HIV and Solid Organ Transplantation: Where Are we Now. Curr HIV/AIDS Rep. 2019 Oct;16(5):404-413. doi: 10.1007/s11904-019-00460-7. PMID: 31482298; PMCID: PMC6813753. ** BTS guidelines
Will you accept this DBD donor? If both the donor and recipient are HIV positive, I will accept them as potential candidates for kidney transplantation.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met? Before accepting donor, any sign of nephropathy should be excluded. Recipient should have · HIV PCR viral count less than 50 and T-Cell CD4 count more than 200 for the past 6months · Life expectancy is more than 5 years · Patient compliant on HAART for the past 6 months · No opportunistic infection for the past 6 months · Counseled about the risk of both high rejection rate and reactivation of viral replications · Malignancy screening
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan? Induction with Basiliximab because the risk of acute and hyperacute rejection is low and continue with the maintenance triple therapy with follow up of graft function . continue on antiretroviral therapy with monitoring of drug interaction. Reference: British Transplantation Society Guidelines
Yes, we can proceed with the donation According to BTS guideline We recommend
All potential kidney transplant recipients are screened for HIV infection (1D)
HIV per se is not a contraindication for kidney transplantation (1B)
HIV-positive patients are wait-listed only if:
a) They are concordant with treatment, particularly cART therapy (1D) b) Their CD4+ T cell count is > 100 cells/microL (ideally > 200 cells/microL) and has been stable the previous 3 months (1B) c) HIV RNA has been undetectable during the previous 6 months (1B) d) No opportunistic infections have occurred during the previous 6 months (1B) e) They have no history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma (1B) We suggest
The most appropriate ART is determined before transplantation in conjunction with an HIV specialist in order to anticipate potential drug interactions and appropriate dosing of medication (Not graded)
Use of HIV-infection donors for HIV-infected recipients We recommend
Transplantation using HIV-infected individuals is restricted to organs from deceased donors with;
a) HIV viral load <50 copies and CD4 count >200 for at least 6 months prior to brain injury. b) Information about the donor virus such as historical genotype patterns where possible and current viral load. c) No history of virological failure or drug resistance (1D)
Recipients are counseled and give informed consent both at the time of listing and Tx (1D)
Patients with HIV infection are not suitable for living donation (1D)
We suggest that
HIV + organ use is restricted to those centers that have experience in Tx HIV+ patients (Not graded)
As a liver donor, we can accept and proceed with the consideration
As the outcome of liver transplantation with HIV+ varies according to the reason for transplantation a) Recipient should be disclosed that he will receive a graft from an HIV+ donor b) The transplantation is confined to HIV D+/HIV R+ c) Liver disease can occur due to HIV infection as a complication of ART. d) HIV-HBV co-infection, the graft, and patient survivals range from 85 to 100% after 3-5 years of follow-up, due to the frequency of breakthrough HBV viremia, lifelong prophylaxis is recommended. e) HIV-HCV co-infection, before DAA the outcome is significantly lower in graft and patients survival, compared to HCV-mono-infection, with estimated 1,3, and 5-years graft survival 52 to 86%, 45 to 60%, and 31 to 45% respectively, while HCV-mono-infection ranged from 57 to 88, 50 to 62, and 358% respectively. If the potential recipient has DSA (A36 with MFI 1550), but negative FCXM
Protocol biopsy (HIVAN, FSGS).
Induction therapy with Basiliximab.
Intensive IS TAC/MMF/Perd.
Refferences
Amico P, Honger G, Mayr M, Steiger J, Hopfer H, Schaub S. Clinical relevance of pretransplant donor-specific HLA antibodies detected by single-antigen flow-beads. Transplantation. (2009) 87:1681–8. doi: 10.1097/TP.0b013e3181a5e034
Lefaucheur C, Loupy A, Hill GS, Andrade J, Nochy D, Antoine C, et al. Preexisting donor-specific HLA antibodies predict outcome in kidney transplantation. J Am Soc Nephrol. (2010) 21:1398–406. doi: 10.1681/ASN.2009101065
Health Protection Agency. HIV in the United Kingdom: 2013 Report. http://www.hpa.org.uk Accessed June 2014. 2. Mocroft A, Ledergerber B, Katlama C, et al. Decline in the AIDS and death rates in the EuroSIDA study: an observational study. Lancet 2003; 362: 22-9. Williams I, Churchill D, Anderson J, et al. British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2012. HIV Med 2012; 13 Suppl 2: 1-85. 4. May MT, Gompels M, Delpech V
I will accept this potential donor, only for HIV positive recipient.
If the recipient is HIV negative, this potential donor will not be suitable and I would not proceed forward in the transplant process.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes, I will accept this donation and proceed in the transplant process with HIV serostatus D+/R+. HIV per se is not a contraindication for kidney transplantation(1).
Transplantation using organs from HIV-infected individuals is restricted to organs from deceased donors if the following conditions are met(1):
a) HIV viral load <50 copies/mL and CD4 count >200/μL for at least 6 months prior to brain injury.
b) Information about the donor virus such as historical genotype patterns where possible and current viral load.
c) No history of virological failure or drug resistance.
The transplant recipient should meet the following criteria: a) HIV RNA has been undetectable during the previous 6 months. b) No opportunistic infections have occurred during the previous 6 months. c) They have no history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
· A36 is rare HLA-A allele group. A36 is more common in Africa (North and East) and Central Asia.
· I will proceed in the transplant process after counselling the transplant candidates and explaining to them the risk of rejection and sequelae of HIV infection in the post-transplant period.
· I will consider induction therapy with Basiliximab (IL-2RA).
· For maintenance IS I will consider the triple of TAC, MMF and prednisolone.
References
1. Kidney & Pancreas Transplantation in Patients with HIV Second Edition Compiled by a Working Party of The British Transplantation Society March 2015 [Minor Revision January 2017]
=Will you accept this DBD donor?
Yes, I will.
The DBD donor should have the following criteria.
1-HIV viral load of <50 copies/ml and CD4 count of >200/microL for minimum 6 months.
2-No history of invasive opportunistic infections, virological failure, or drug resistance.
3-To rule out HIV associated nephropathy (HIVAN) . Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met? No, I will not accept.
Transplantation using organs from HIV-infected individuals is restricted to organs from deceased donors with special criteria as mentioned above, patients with HIV-infection are unsuitable to be living kidney donors and no clear consensus guidelines about this issues.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
We can proceede with use of induction therapy (Basiliximab) and maintenance immunosuppression in form of Tacrolimus, Mycophenolate mofetil and steroids.
We should be cautious about antiretroviral with nephrotoxic potential and with significant drug interaction with tacrolimus .
Prophylaxis for pneumocystis jirovecii should be given, CMV prophylaxis for minimum 3 months for D+/R- pair and Toxoplasma prophylaxis in setting of donor seropositive for Toxoplasma should be given.
Monitoring of HIV RNA and CD4 count at 1 month, and then every 2-3 months till 12 months, and then 3-6 monthly.
Post-transplant monitoring of DSA and a protocol biopsy at 3 months should be done .
References:
1. British Transplantation Society. Kidney and Pancreas Transplantation in patients with HIV.
2. Blumberg EA, Rogers CC; American Society of Transplantation Infectious Diseases Community of Practice. Solid organ transplantation in the HIV-infected patient: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13499. doi: 10.1111/ctr.13499. Epub 2019 Apr 21. PMID: 30773688.
3. Sawinski D. Kidney Transplantation in Patients with HIV. Kidney360. 2020 May 6;1(7):705-711. doi: 10.34067/KID.0002112020. PMID: 35372947; PMCID: PMC8815555.
Did you mention in the first question the R should be also +ve for HIV?!
Your second choice is clear that an HIV living donor is not a suitable donor strictly speaking!
Will you accept this DBD donor?
Yes, I will accept this deceased donor (for HIV recipient)with:
1. HIV viral load <50 copies/mL and CD4 count >200/µL for at least 6 months prior to brain injury
2. Information about the donor virus such as historical genotype patterns where possible and current viral load
3. No history of virological failure or drug resistance
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes, I will accept HIV1 to HIV+
HIV+ transplant recipient criteria:
1. They are concordant with treatment, particularly cART therapy
2. Their CD4+ T cell counts are >100 cells/µL (ideally > 200 cells/ µL) and have been stable during the previous 3 months (1B)
3. HIV RNA has been undetectable during the previous 6 months
4. No opportunistic infections have occurred during the previous 6 months
5. They have no history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma
The risk of HIVAN recurrence is high if the donor is HIV+ (screen donor HIVAN)
The most extensive experience in the use of HIV kidney donors comes from South Africa. To 2020, they have transplanted 51 recipients of HIV donor kidneys; with 1-year patient survival of 87% and 1-year death-censored allograft survival of 96%.
Monitor CD4 count and HIV VL at 1 month post-transplant and every 2–3 months thereafter
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
o Induction therapy at the time of transplantation with IL-2RA (basiliximab)
o Maintenance immunosuppressions started at the time of kidney transplantation, include steroids, a CNI and an anti-proliferative agent (1C)
o Explain the high risk of acute rejection (treated in the same way as HIV-negative kidney transplant recipients)
References
1. Kidney & Pancreas Transplantation in Patients with HIV, BTS guidelines, March 2015.
2. Sawinski, Deirdre. Kidney Transplantation in Patients with HIV. Kidney360 1(7):p 705-711, July 2020. | DOI: 10.34067/KID.0002112020
The index donor is a DBD (donor after brainstem death) donor with good renal function and negative HBV and HCV, but a positive HIV report.
Yes, this donor can be accepted, but only for HIV positive recipient.
The DBD donor should also fulfil certain criteria before accepting such a donor, which include HIV viral load of <50 copies/ml and CD4 count of >200/microL for minimum 6 moths prior to the brain injury and no history of invasive opportunistic infections, virological failure, or drug resistance. The urine analysis of the donor should not be having anu proteinuria/ hematuria, and if needed, a pre-implantation kidney biopsy to rule out HIV associated nephropathy (HIVAN) should be performed (1).
The prospective recipient should be counselled regarding the risk of transmission of opportunistic infections, other HIV strains, and viral resistance prior to proceeding with transplant (1,2).
The prospective recipient should also fulfil certain criteria which include being concordant with cART treatment, having undetectable HIV RNA for last 6 months, CD4 count >100/microL (ideally >200/microL) for more than 3 months, absence of opportunistic infection in last 6 months, and no history of lymphoma, cryptosporidiosis, and progressive multifocal leukoencephalopathy.
The transplant should take place in a center with experience in managing such transplants.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
According to the British Transplantation Society guidelines, HIV-infection makes a person unsuitable as a living kidney donor (1).
Nevertheless, a prospective donor with HIV-positive status can be accepted as a living donor for a HIV-positive recipient if certain criteria are fulfilled as per the HOPE Act.
Donor evaluation: A living donor should undergo all the routine pre-donation work-up as per protocol for all donors. In addition, the donor should also fulfil criteria including CD4 count>500/microL for last 6 months, and HIV RNA <50 copies/ml and no invasive opportunistic complications of HIV (3). They should undergo a pre-implantation biopsy (4). The donor should not have APOL1 variant, as it is associated with high risk of subsequent renal disease to both the donor and recipient.
Recipient evaluation: The recipient, in addition to the transplant work-up protocol for a routine HIV-negative transplant candidate, must fulfill certain other criteria which include being concordant with cART treatment, having undetectable HIV RNA for last 6 months, CD4 count >100/microL (ideally >200/microL) for more than 3 months, absence of opportunistic infection in last 6 months, and no history of lymphoma, cryptosporidiosis, and progressive multifocal leukoencephalopathy. Pre-transplant assessment for syphilis, HSV (Herpes simplex virus), EBV (Epstein Barr virus), CMV (cytomegalovirus), VZV (varicella zoster virus), HTLV (human T-cell leukemia virus), Toxoplasma gondii, active tuberculosis, latent Tuberculosis, HBV, HCV, cervial and/or anal neoplasia evaluation should be done (1).
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
If the index recipient has DSA (A36 with MFI 1550), but FCXM is negative, the transplant can be proceeded with use of induction therapy (Basiliximab) and maintenance immunosuppression in form of Tacrolimus, mycophenolate mofetil and steroids. Antiretrovirals with nephrotoxic potential and with significant drug interaction with tacrolimus should be changed prior to transplant.
Post-transplant, lifelong prophylaxis for pneumocystis jirovecii should be given. CMV prophylaxis for minimum 3 months for D+/R- pair and Toxoplasma prophylaxis in setting of donor seropositivity for Toxoplasma should be given.
HIV RNA and CD4 count should be monitored at 1 month, and then every 2-3 months till 12 months, and then 3-6 monthly.
Post-transplant monitoring of DSA and a protocol biopsy at 3 months should be done (5). In presence of antibody mediated rejection (AMR) in biopsy, treatment should be done. If the DSA is increasing, then the immunosuppression should not be reduced. If the DSA is not increasing, and there is no AMR, then follow-up DSA level should be tested at 12 months and whenever there is any significant change in immunosuppression, graft dysfunction, or suspected non-adherence (5).
Sawinski D. Kidney Transplantation in Patients with HIV. Kidney360. 2020 May 6;1(7):705-711. doi: 10.34067/KID.0002112020. PMID: 35372947; PMCID: PMC8815555.
Blumberg EA, Rogers CC; American Society of Transplantation Infectious Diseases Community of Practice. Solid organ transplantation in the HIV-infected patient: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13499. doi: 10.1111/ctr.13499. Epub 2019 Apr 21. PMID: 30773688.
Health Resources and Services Administration; Department of Health and Human Services. Final Human Immunodeficiency Virus Organ Policy Equity (HOPE) Act safeguards and research criteria for transplantation of organs infected with HIV. Fed Reg. 2015;80:34912‐34921.
Tait BD, Süsal C, Gebel HM, Nickerson PW, Zachary AA, Claas FH, Reed EF, Bray RA, Campbell P, Chapman JR, Coates PT, Colvin RB, Cozzi E, Doxiadis II, Fuggle SV, Gill J, Glotz D, Lachmann N, Mohanakumar T, Suciu-Foca N, Sumitran-Holgersson S, Tanabe K, Taylor CJ, Tyan DB, Webster A, Zeevi A, Opelz G. Consensus guidelines on the testing and clinical management issues associated with HLA and non-HLA antibodies in transplantation. Transplantation. 2013 Jan 15;95(1):19-47. doi: 10.1097/TP.0b013e31827a19cc. PMID: 23238534.
This donor will be accepted in case of HIV positive recipient ,the HIV Organ Policy Equity Act has opened and expanded opportunities for PWH to donate and receive organs because transplantation provides a clear survival benefit over renal replacement therapy .
But for PWH to be listed for transplantation they should fulfill the following criteria :
– Being controlled on regular cART therapy
– Have undetectable HIV RNA level for at least 6 month
– CD4+T Cell count >200 cells/µL
– No opportunistic infection in the last 6month
-No history of progressive multifocal leukoencephalopathy or lymphoma .
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
People with HIV were allowed to be living donors but they should meet all requirements of the transplant center with CD4 count over 500 and undetectable viral load plus negative history of invasive infections ,kidney biopsy is mandatory in those patients to exclude HIVAN .
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
– Presence of DSA in patients with negative FCXM is not contraindication to transplantation so I will proceed .
– The management plan will be induction with Basiliximab because the risk of acute and hyperacute rejection is low and continue with the maintenance triple therapy with follow up of graft function . continue on antiretroviral therapy with monitoring of drug interaction .
Reference :
1. AIDS. 2020 Jul 1;34(8):1107-1116. doi: 10.1097/QAD.0000000000002518. 2. Nephrol Nurs J. 2017 May-Jun;44(3):230-249 3. British Transplantation Society Guidelines
as I am working in center that doesn’t have experience in treatment of HIV I Will not accept
but in other centers that have experience in ttt of HIV , the HIV deceased donor can be accepted in the following conditions
1. HIV viral load <50 copies/mL and CD4 count >200/μL for at least 6 months prior to brain injury 2. Information about the donor virus such as historical genotype patterns where possible and current viral load 3. No history of virological failure or drug resistance
4. no evidence of active opportunistic infections 5. Absence of chronic wasng or severe malnutrion 6. informed consent should be given 7. Pre- implantation biopsies may be considered to detect donor disease as HIV at risk of CKD ·
as a living donor HIV patients are not stable for organ donation
IF recipient has DSA (A36 with MFI 1550), but negative FCXM.
I would prefer Basiliximab for induction
In the U.S. NIH observational trial, persons who received ATG as opposed to basiliximab, experienced significant, prolonged lymphocyte depletion, more frequent and severe infections, and increased risk for allograft loss . Other investigators, through analysis of registry data, reported lower rejection and infection rates with ATG .Based on this, choice of induction agent should be individualized
As per British society of organ transplanation kidney transplant is the best RRT for HIV ESRD patients associated with better morbidity and mortality.
As long as both donor and recipient are HIV positive so i will accept them as potential candidates for kidney transplantation with special precautions as
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Kidney donor should be healthy individual with low risk of developing ESRD.HIV are in risk of developing HIVAN so,i will not accept him as potential donor but if he/she insist to donate after proper counseling about risk and benefits i will proceed if urine analysis showed no proteinuria and kidney biopsy was normal.
regarding recipient, he/she
HIV PCR viral count less than 50 and T-Cell CD4 count more than 200 for the past 6months
life expectancy is more than 5 years
patient compliant on HAART for the past 6months
patient has no opportunistic infection for the past 6m
counseled about the risk of both high rejection rate and reactivation of viral replications
screened for malignancies
plus the usual precautions for non HIV potential candidates
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
HIV patient is high risk patient with high risk of rejection.some centers routinely do protocol biopsy for this specific group of patients.
DSA against class I even with low MFI consider more risk for already risky patient
I would prefer to wait for better offer unless patient in urgent need to organ due to failed vascular access or highly sensitized patient on the waiting list for long period and he was counseled regarding risk of rejection which will need aggressive treatment with risk of viral reactivation and short term graft survival and still accepting to proceed.
as long as FCXM is negative no need for desensitization and i will go with basiliximab non depleting induction with maintenance triple immunosuppresion including TAC,MMF and steroids. References
British Transplantation Society Guidelines. Kidney & Pancreas Transplantation in Patients with HIV March 2015 [Minor Revision January 2017]
Will you accept this DBD donor?
-Yes, Transplant candidates need precise immuno-virological and antiretroviral status evaluation as CD4 cell count, HIV RNA level, present and previous antiretroviral treatments, HLA-B5701 status and HIV resistance profile.
HIV-infected deceased donors to be suitable for transplantation has to have
-HIV viral load <50 copies/mL and CD4 count >200/µL for at least 6 months before brain injury
-Information about the donor virus such as historical genotype and viral load
-No history of drug resistance
· Recipients are counselled and give informed consent both at the time of listing and at the time of transplantation · Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes ,Cases having HIV RNA levels <200 copies/mL can be suitable for transplantation if all other issues are in acceptable range.
• Possible donors for HIV infected cases have to be informed of medical, surgical, and psychosocial factors that can affect the recipient’s morbidity and mortality risk but disclosing the recipient’s HIV status is not a must
• guidelines on the ethics of living donor transplantation need to be followed for all transplantation including those with HIV disease and the same standard of consent
• Transplant teams must guarantee the adequacy of donor consent and the transparency of procedures in advance
· the recipient is encouraged to inform their diagnosis of HIV to their donors
· the donor must be asked if there is any medical disease that can let them reject donation without saying it is HIV also donors have to be informed that there is a medical condition the recipient has but is unrevealed
· living donors need to be acknowledged that they are aware that confidential data concerning the recipient won’t be told to them
It is suggested that HIV+ organ transplant to be carried out only in centres that have experience in transplanting HIV+ cases
Patients with opportunistic infections and neoplasms without effective medical therapy are excluded as progressive multifocal leukoencephalopathy (PML), chronic intestinal cryptosporidiosis. Visceral and systemic Kaposi’s sarcoma are no longer contraindicated, as long as the disease is successfully eradicated with the use rapamycin
All possible recipients are routinely screened for TB , syphilis and hepatitis C pre-transplant. As well as strongyloidiasis screening in epidemic area
Treatment/screening for co-infection for HBV/HCV are needed before transplantation.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Induction of therapy can be IL2 receptor antagonist but TB screening is needed before therapy
Maintenance Tac MMF ,prednisolone
Prophylaxis against fungal infections, Pneumocystis pneumonia (PCP), and Cytomegalovirus infection (CMV)
Pneumococcal Polysaccharide Vaccine (PPSV) and Pneumococcal Conjugate Vaccine (PCV) should be given pretransplant
The interaction between protease and non-nucleoside reverse transcriptase inhibitors with the calcineurin and mTOR inhibitors, is challenging rendering treatment difficult , with close drug monitoring Reference
-Kidney & Pancreas Transplantation in Patients with HIV .Second edition ,Compiled by a Working Party of The British Transplantation Society March 2015 [Minor Revision January 2017]
-Muller E, Botha FCJ, Barday ZA, Manning K, Chin-Hong P, Stock P. Kidney Transplantation in HIV-positive Patients: Current Practice and Management Strategies. Transplantation. 2021;105(7):1492-1501.
Thankyou the viral load should be less than 50 copies.
This is a LD so he should also get a fair attention and follow up for virus status and proteinuria.
Will you accept this DBD donor? I will accept this donor for HIV positive recipients only. Certain criteria have to be met for donor: · HIV Viral load < 50 copies /ml · CD 4 counts > 200 at least 6 months prior to brain injury · Where possible info on current viral load and genomic pattern · Absence of drug resistance · HIVAN is excluded Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met? YES I will accept him Potential HIV positive donors should be informed about medical , surgical and psychological implications and recipient morbidity. Information pertaining to recipient need not to be disclosed.
Pre requisites for Kidney donation: HIV Viral load < 50 copies /ml CD 4 counts > 200 at least 6 months prior to brain injury Where possible info on current viral load and genomic pattern Absence of drug resistance HIVAN is excluded
Pre requisites for recipients Undetectable viral load for 6 months Compliance with cART Cd 4 Counts > 200 cells/ml for > 3 months No opportunistic infection in last 6 months No evidence of HIV related malignancy Ability to have regular follow ups Recipients have to be counselled in detail and transplant centres should preferably have experience in HIV positive transplantation. History of Vaccination- MMR, Influenza, VZV, Pneumococcal, DTP, HPV, Heepatitis A , B Have to take history of infections like EBV, Tuberculosis, Mycobacterium Avium, Toxoplasma Gondii, , CMV etc
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan? I will proceed with Basiliximab induction and triple immune suppression as TAC, MMF and Prednisolone. All pre requisites for donor and recipient have to be met CD4 counts and HIV RNA quantitative monitoring
Botha J, Fabian J, Etheredge H, Conradie F, Tiemessen CT. HIV and Solid Organ Transplantation: Where Are we Now. Curr HIV/AIDS Rep. 2019 Oct;16(5):404-413. Muller E, Barday Z, Kahn D. HIV-positive-to-HIV-positive kidney transplantation. N Engl J Med. 2015 May 21;372(21):2070-1. doi: 10.1056/NEJMc1503288. PMID: 25992753; PMCID: PMC4633687.
A 51-year-old male DBD donor donated kidneys from SAH-complicating cerebral aneurysm with 78 µmol/L retrieval, negative for HBV, HCV, but HIV is positive. Will you accept this DBD donor? Yes, I will accept this donorto HIV infected recipient after fulfilling the following criteria: After counseling the recipient patient. Viral load > or = 200/ml for at least 6 months before the brain injury.
Excluding HIVAN by absence of proteinuria and a kidney biopsy.
With continuation of HAART after transplant and the recipient fit for intervention.
Would you accept this donor as a live donor if the recipient is also HIV positive? HIV Organ Policy Equity Act- 2013)
The viral load is undetectable or less than 50 copies/ml and CD4 > 200 for the last 6 months.
No evidence of HIV associated nephropathy by performing a kidney biopsy and checking for proteinuria.
Has no evidence of invasive infection, PCP, or active fungal meningitis.
Meet all the requirement of the transplant center.
Transplants may be the only option to prolong life for HIV/AIDS patients with end-stage organ disease.
Patients with ESRD should have a life expectancy of at least five years before transplantation.
HIV-associated nephropathy is the most common cause of ESRD in HIV-infected patients, especially in black patients.
HIV-positive patients on dialysis have improved survival and morbidity, but the complexities of antiretroviral therapy dosing have prompted consideration of renal transplantation.
HIV infection is no longer an absolute contraindication for renal and liver transplants to stable HIV-positive patients.
Graft and patient survival are comparable to non-HIV infected recipients of both cadaveric and live-related donor kidney transplants, but there are still issues to address. BTS Guidelines:
HIV per se is not a contraindication for kidney transplantation. (1B)
Recipients are counselled and give informed consent both at the time of listing and at the time of transplantation. (1D)
HIV+ organ use is restricted to those centres that have experience in transplanting HIV+ patients. (Not graded)
Transplantation using organs from HIV-infected individuals is restricted to organs from deceased donors with:
a) HIV viral load < 50 copies/mL and CD4 count > 200/µL for at least 6 months prior to brain injury,
b) Information about the donor virus such as historical genotype patterns where possible and current viral load,
c) No history of virological failure or drug resistance. (1D) If yes, what are the conditions that should be met? The Recipient Should Fulfill the Following Criteria:
Fit with life expectancy of > Five years.
Concordant with HAART therapy (1D)
CD4+ T cell counts are >100 cells/μL (ideally > 200 cells/ μL) and have been stable during the previous 3 months (1B).
Fully HIV RNA load and CD4 > 100 (2C).
HIV RNA undetected or less than 50 copies/ml for the last 6 months (1B). No history of opportunistic infection for the last 6 months (1B).
No history of PML (Progressive multifocal leukoencephalopathy), chronic intestinal cryptosporidiosis, or lymphoma (1B).
All potential kidney transplant recipients are screened for HIV infection (1D) HIV per se is not a contraindication for kidney transplantation (1B) HIV-positive patients are wait-listed only if: They are concordant with treatment, particularly cART therapy (1D)
Their CD4+ T cell counts are >100 cells/μL (ideally > 200 cells/ μL) and have been stable during the previous 3 months (1B)
HIV RNA has been undetectable during the previous 6 months (1B)
No opportunistic infections have occurred during the previous 6 months (1B)
They have no history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma. Relative contraindications to kidney transplantation:
Positive flow cytometric crossmatch (FCXM) (1D)
ABOi Blood-type incompatibility (2D)
Treated malignancy, including extracutaneous Kaposi sarcoma (2C)
Severe and/or uncontrolled medical problems that are unlikely to improve after kidney transplantation and will shorten the patient’s life expectancy (2D)
Chronic liver disease (2D)
Marked obesity (BMI >35 kg/m 2) (2D)
HTLV infection (1D
The following should be considered absolute contraindications: Uncontrolled HIV infection (CD4+ T cell levels persistently < 100 cells/μL during the last 6 months and HIV RNA persistently detectable during the last 3 months) (1C).
Non-compliance with anti-retroviral therapy (1D).
Positive CDC crossmatch (1D).
Anti-HIV drug resistance and lack of future HIV treatment options (1D). Previous or current infections that are at high risk of re-activating with immune suppression: –
• Aspergillus – infection or colonisation
• Any multi-resistant fungal infections
• Cytomegalovirus (CMV) disease with any activity and unresponsive to first line therapy.
• Influenza or RSV infection within 30 days
• Active bacterial infections
• Mycobacterial infections – unless there is clear evidence of successful treatment Advanced cardiopulmonary disease
History of neoplasms except solid tumours adequately treated and disease-free survival documented for > five years (consult IPTTR pre-listing)
HTLV-1 positive patients
Patients with significant human papilloma virus (HPV) associated advanced cervical and anal intraepithelial neoplasia (CIN/AIN III) and carcinoma in situ need to be excluded.
Hepatic cirrhosis (F4 fibrosis by Metavir if HBV/HCV co-infection) and evidence of active viral replication if HBV/HCV co-infected
Pregnancy.
Continuing use of illicit recreational drugs (Recreational drugs include analgesics, depressants, stimulants, and hallucinogens.) BTS Guidelines:
Selection and assessment before transplantation.
Patients with HIV-infection are unsuitable to be living kidney donors. (1D)
HIV-positive patients are wait-listed only if:
a) They are concordant with treatment, particularly cART therapy. (1D)
b) Their CD4+ T cell counts are >100 cells/µL (ideally > 200 cells/ µL) and have been stable during the previous 3 months. (1B)
c) HIV RNA has been undetectable during the previous 6 months. (1B)
d) No opportunistic infections have occurred during the previous 6 months. (1B)
e) They have no history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma. (1B)
Consent and confidentiality:
Existing guidelines on the ethics of deceased donor and living donor transplantation are followed for all transplantation involving people with HIV disease. (Not graded)
The standard of consent for HIV-positive transplant candidates is the same as for any other transplant. (Not graded)
Transplant teams must be satisfied that donor consent is adequate and that procedures for ensuring this are transparent and established in advance. (Not graded)
Wherever possible, the recipient is encouraged to disclose their diagnosis of HIV to their donor. (Not graded)
All living donors are asked whether there are any medical conditions that would cause them to change their decision to donate, without highlighting HIV. (Not graded)
All living donors are made aware that there may be medical and social information about the recipient that is not disclosed. (Not graded)
All living donors are asked to acknowledge that they are aware that they will not be given confidential information about the recipient which is not deemed relevant to the outcome of the kidney transplant (Not graded)
Screening before transplantation:
All transplant candidates undergo careful immuno-virological and antiretroviral status review. This includes CD4 cell count, HIV RNA level, current and prior antiretroviral therapies, HLA-B5701 status and HIV resistance profile. (1D)
Patients with HIV RNA levels < 200 copies/mL may be considered suitable for solid organ transplantation if otherwise well and fully adherent with their medications. (1C)
Transplant candidates undergo serologic testing for syphilis, herpes simplex virus, Epstein-Barr virus, cytomegalovirus, varicella zoster virus, human T-cell leukaemia virus and Toxoplasma gondii. (1D)
Transplant candidates are tested for latent Mycobacterium tuberculosis infection with an interferon-gamma test with or without a concurrent Mantoux test following the testing strategy for immunocompromised patients in the current NICE Tuberculosis Guidelines. (1C)
Transplant candidates who test positive for latent Mycobacterium tuberculosis infection are assessed for any evidence of active tuberculosis disease. (1C)
Transplant candidates with evidence of active tuberculosis disease are treated according to current NICE guidance prior to transplantation. (1C)
Transplant candidates with latent Mycobacterium tuberculosis infection, in whom active disease has been excluded are treated for latent Mycobacterium tuberculosis infection, according to current NICE TB guidelines, prior to transplantation. (1C)
All transplant candidates are screened for viral hepatitis. Those found to be hepatitis B surface antigen or hepatitis C antibody positive should have their hepatitis B DNA / hepatitis C RNA levels quantified and be investigated for the presence of liver cirrhosis. (1C)
All hepatitis B surface antigen positive patients who are wait listed for solid organ transplantation receive treatment to ensure hepatitis B DNA is fully suppressed(1B).
Patients considered for solid organ transplantation are assessed for the presence of cervical and/or anal neoplasia; those with advanced cervical/anal intraepithelial neoplasia (CIN/AIN III) or carcinoma in situ should receive treatment prior to transplantation. (1D)
Pre-transplant immunization:
Hepatitis B virus (HBV) vaccine is administered to all non-immune patients (HBV surface antibody titres < 10 mIU/mL). (1B)
Hepatitis A virus (HAV) vaccine is administered to all non-immune patients. (1D)
Pneumococcal polysaccharide vaccine (PPV-23) is administered to all patients. (1B)
Varicella zoster vaccine (VZV) vaccine is administered to non-immune patients with CD4 cell counts >200 cells/µL. (1C)
Influenza vaccine is administered annually to patients awaiting solid organ transplantation. (1B) Diphtheria, tetanus and pertussis (DTP) vaccine is administered to all patients. (2D)
Measles, mumps and rubella (MMR) vaccine is administered to all patients who are nonimmune to measles. (2D)
Human papilloma virus (HPV) vaccine is offered to patients at risk of HPV acquisition. (2C)
Post-transplant prophylaxis:
HIV-positive transplant recipients receive lifelong prophylaxis against Pneumocystis pneumonia following transplantation. (1D)
Prophylaxis against cytomegalovirus is indicated in CMV seronegative recipients of organs from CMV seropositive donors for a minimum of 3 months. (1A)
CMV seropositive transplant recipients receive either prophylaxis against CMV infection or PCR surveillance and pre-emptive therapy for a minimum of 3 months. (1A)
Transplant patients who are well and were not assessed and treated for Mycobacterium tuberculosis latent infection or disease before transplantation should be assessed as recommended for patients prior to transplantation. (1C)
-Transplant patients who are well and were assessed and treated for Mycobacterium tuberculosis latent infection or disease before transplantation do not need reassessment for Mycobacterium tuberculosis latent infection unless there is a new history of exposure to tuberculosis. (1C)
Transplant patients who are re-exposed to tuberculosis after transplantation should be assessed for Mycobacterium tuberculosis latent infection and/or disease as recommended in current NICE TB guidance on tuberculosis contact tracing. (1C)
Toxoplasma IgG seropositive recipients with a CD4+ count < 200 cells/µL or any recipient of an organ from a donor seropositive for toxoplasmosis receive lifelong prophylaxis. (2C)
Prophylaxis against Mycobacterium avium complex (MAC) is indicated when the CD4+ ≤ 50 cells/µL, and it be stopped when the CD4 count is >100 cells/µL for 6 months. (2D) Monitoring of HIV virological control:
Quantitative HIV RNA and CD4+ T-cell counts are measured regularly, with the first assays at 1 month after transplant and subsequent studies every 2-3 months for the first year then every 3-6 months thereafter. (1B)
If patients have persistent HIV viraemia, drug-resistance testing is carried out to determine treatment options. (1D)
More frequent monitoring of CD4 count may be necessary in patients receiving depleting antibodies to determine the need for anti-infective prophylaxis. (2D) Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan? Yes, I will proceed to transplantation as DSA positive is not a contraindication for transplantation, with this low MFI to A36 – (found in African) The greater incidence of rejection episodes can be explained if (FCXM positivity is a relative contraindication for HIV transplant).
HIV-positive kidney transplant recipients are treated similarly to HIV-negative recipients, with pre-transplant vaccines and post-transplant CMV treatment.
The transplant procedure should not be prevented by the presence of DSA, but MFI values more than 2000 are significant and may not be well correlated with allograft outcomes.
I will counsel the patient about it and inform him or her that he is immunologically at high risk of being HIV positive due to immune dys-regulation. This is done to rule out co-infection in the recipient, whether it be HIV/HBV or HIV/HCV.
I will continue with the transplantation, followed by IL 2RA (Basiliximab) induction and triple immune suppression maintenance (CNIs, MMF, and Prednisolone).
It should be to do post-transplant DSA monitoring, biopsy, and other parts of treatment such routine HIV RNA monitoring, immunizations, and long-term PCP prevention.
Reference: British Transplantation Society Guidelines (BTS) kidney and pancreas transplantation in patients with HIV March 2015 [Minor Revision January 2017] Second Edition.
Sawinski D. Kidney Transplantation in Patients with HIV. Kidney360. 2020;1(7):705-711. Published 2020 May 6. doi:10.34067/KID.0002112020
This is a DBD donor who is HIV positive and has good kidney function
Being HIV positive, the organs can only be offered to HIV positive recipients
A history of his HIV disease and treatment should be sought to assess if he has had treatment failure due to the risk of HIV superinfetion
The potential recipient should be counseled that he is getting an HIV positive donors organ
The potential recipient should:
Have a CD4 count of more than 200 cells/microliter for at least 3 months
Have an undetectable VL
Have no h/o opportunistic infections in the past six months
Have been compliant to the ARTs and clinic visits
Have no history of PML or malignancy
If the donor was a live donor and if the recipient was HIV positive:
The donor should have a suppressed VL and preferrable a CD4 of more than 200:
He should be ABO compatible, CDC crossmatch negative and flow cytometry negative
He should not have active infection or malignancy
For the recipient
Have a CD4 count of more than 200 cells/microliter for at least 3 months
Have an undetectable VL
Have no h/o opportunistic infections in the past six months
Have been compliant to the ARTs and clinic visits
Have no history of PML or malignancy
For a DSA positive with MFI 1550 and negative flow cytometry:
I would still proceed with the transplant
The question would arise about the choice of the induction agent: ATG versus basiliximab
ATG has been shown to be superior for reducing the rejection episodes but in HIV positive recipients, it will lower the CD4s for a prolonged duration with a hypothetical risk of increased opportunistic infections. However, some studies reported no increased risk of increased opportunistic infection and lower rates of rejection.
I would go for ATG induction
The maintenance ISS would be tacrolimus based with close monitoring of the drug levels
The patient should be assessed for latent TB before transplant and if present should be treated appropriately
He should receive prophylaxis for PJP and CMV
Organ transplantation in persons with HIV AIDS 2020, 34:1107–1116
Will you accept this DBD donor?
I will accept this donor only if the recipient is also HIV positive and have following perquisites.
For Donor
HIV viral load <50 copies/mL
CD4 count >200/μL for at least 6 months prior to brain injury
Information about the donor virus (genotype patterns) where possible & current viral load
Absence of H/O virological failure or drug resistance (1D)
And HIVAN is excluded.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes, I will accept him on following ground.
Patients with HIV infection have the same access to living donor kidney transplantation as non-infected patients (1B)
Potential donors for patients with HIV infection are informed of medical, surgical, and psychosocial factors that may heighten the recipient’s morbidity and mortality risk, but that disclosure of the recipient’s HIV status is not mandatory (Not graded)
Patients with HIV-infection are unsuitable to be living kidney donors (1D)
Prerequisite for For Donor
-HIV viral load <50 copies/mL
-CD4 count >200/μL for at least 6 months prior to donation
-now about the donor virus (genotype patterns) where possible & current viral load.
-Need to know absence of H/O virological failure or drug resistance (1D)
-Have to exclude HIVAN.
Prerequisite For recipient
-Undetectable HIV viral load for previous 6 months
-C4D count > 200 cells /ml and stable for more than previous 3 months
-Is compliance with cART
-No evidence of active opportunistic infections for at least the last 6 months
-No evidence of HIV-associated malignancy
-Ability to have a close follow-up for immunosuppression, drug-level monitoring, and management
-The recipients are counselled & give informed consent both at the time of listing & at the time of transplantation (1D)
-The transplant center should have experience in transplanting HIV+ patients (Not graded)
Will take history regarding vaccination and natural infection and investigation to exclude the disease.
Vaccination: DTP, MMR, pneumococcal, hemophilus influenza, Meningococcus, Influenza, VZV, hepatitis A, B, HPV,
Infection: strongyloidosis, syphilis, herpes simplex virus, Epstein-Barr virus, cytomegalovirus, human T-cell leukaemia virus, and Toxoplasma gondii, hepatitis b, c, latent tuberculosis, microbacterium avium
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
In this case the patient is consider as standard risk so, I will proceed with tacrolimus, MMF & prednisolone maintenance therapy and Induction with Basiliximab.
The prerequisite of donor and recipient and screening of infection is as of answer to question 2
Need to Monitor
Quantitative HIV RNA and CD4+ T-cell counts are measured regularly, with the first assays at 1 month after transplant and subsequent studies every 2-3 months for the first year then every 3-6 months thereafter (1B)
If patients have persistent HIV viraemia, drug-resistance testing is carried out to determine treatment options (1D
Drugs
Pre-emptive switching away from boosted protease-inhibitors (PI)-based antiretroviral regimens, if alternatives exist, in order to minimize drug interactions (2D)
A dose-finding trial of calcineurin-inhibitors prior to solid organ transplantation in order to determine optimum doses to initiate post-transplant (2D)
Cytomegalovirus is indicated in CMV seronegative recipients of organs from CMV seropositive donors for a minimum of 3 months (1A)
CMV seropositive transplant recipients receive either prophylaxis against CMV infection or PCR surveillance and pre-emptive therapy for a minimum of 3 months (1A)
Toxoplasma IgG seropositive recipients with a CD4+ count <200 cells/µL or any recipient of an organ from a donor seropositive for toxoplasmosis receive lifelong prophylaxis (2C)
Prophylaxis against Mycobacterium avium complex (MAC) is indicated when the CD4+ count is ≤ 50 cells/µL, and it be stopped when the CD4 count is >100 cells/µL for 6 months (2D)
References
1.British Transplantation Society Guidelines. Kidney & Pancreas Transplantation in Patients with HIV March 2015 [Minor Revision January 2017]
2.Prof. Ahmed Halawa lecture on HIV
Will you accept this DBD donor?
For the indexed case of HIV-positive DD yes I will accept him for HIV-positive recipients only provided the recipient accepts the offer and has been counseled earlier and get consented, and he medically fits the eligibility criteria for transplantation including he is not in active viremia with confirmed negative viral load < 50 copies, C4D count > 200cells/ml for the last 6 months, no evidence of active infection or active malignancy, well adherence to antiviral therapy and no history of drug-resistant. Recipients should routinely be screened for tuberculosis, syphilis, and hepatitis C pre-transplant. Similarly, in places with epidemiologic risks, strongyloidiasis screening may be needed.Treatment/screening for co-infection for HBV/HCV should be done prior to transplant.
PWH can donate organs to HIV +VE recipients waiting for kidney or liver transplants in research settings in the US through the HOPE act HIV DD eligibility criteria for a donation. Includes HIV donor-specific data from the HIV specialist such as ART history, HIV genotypic testing, C4D cell counts, HIV viral load results, and history of opportunistic complications, so that donor suitability can be established.
Discuss with the recipient the option of the IS and should be on a stable dose of ART for at least 3 months before transplantation some preferred to avoid the use of protease inhibitors due to severe drug interaction with CNI and m TOR inhibitors that put the patient at risk of rejection with underdosing or drug toxicity with overdosing. better outcomes had been reported with integrase strand transfer inhibitor-based antiretroviral regimens. As these regimens have no interaction with calcineurin inhibitors, However, integrase inhibitors are not available worldwide and people still used PI as CNI-sparing agents and reduce the drug cost which is the common practice in Africa. we need combined care and follow-up with HIV specialist and transplant team with frequent monitoring of viral load and C4d count especially during treatment for acute rejection also avoid fixed drug combination as it can be associated with increased risk of AKI and need prolonged chemoprophylaxis for PJP, CMV, fungal infection
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
using HIV-infected live donors is not recommended and evidence is very limited to case reports, as they are at risk of wide range of renal diseases including HIVAN, glomerular diseases like FSGS, IC – mediated MGN, MPGN, tubulointerstitial nephritis, drug and viral-related metabolic effects, and nephrotoxicity. However, there is a reduction in HIV-related CKD with the use of ART and according to recent studies, the prevalence of chronic kidney disease among HIV-infected patients receiving treatment is between 8% and 22% (2).The decision should be individualized case by case and center-based policy to accept such donors provide they have good experience and includes a stable HIV course donors with no proteinuria and a kidney biopsy confirm no evidence of HIVAN, no DM or hypertension, and a normal BMI
HIV-positive African American persons with high-risk apoprotein L1 (APOL1) genotypes are at risk for the development of HIVAN and focal segmental glomerulosclerosis
based on the limited evidence i would not accept donation from alive HIV +ve patient , donor referred to healthy person not have medical complications
. Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan? HIV-positive recipients reported a higher rate of rejection based on the evidence around 15% in the first year then 20% in 2 years and even 30% after3 years, mostly due to the drug-drug interaction and inconsistency of the drug levels which is more with PI ART so for this patient with already have a low titer of preformed DSAfor HLA A36 needs frequent monitoring and use of integrase inhibitors based ART would be safer after transplantation and go ahead with the transplantation providing his FXCM negative, induction still can go with basiliximab vs ATG followed by triple IS including tacrolimus, MMF, prednisolone References 1. Kumar RN, Stosor V. Organ transplantation in persons with HIV. AIDS. 2020 Jul 1;34(8):1107-1116. 2. Muller E, Barday Z, Kahn D. HIV-positive-to-HIV-positive kidney transplantation. N Engl J Med. 2015 May 21;372(21):2070-1 3.Muller E, Botha FCJ, Barday ZA, Manning K, Chin-Hong P, Stock P. Kidney Transplantation in HIV-positive Patients: Current Practice and Management Strategies. Transplantation. 2021 Jul 1;105(7):1492-1501.
HIV-positive dialysis patients had better survival and morbidity, although antiretroviral medication administration is complicated.
Stable HIV-positive people can receive kidney and liver transplants.
Although cadaveric and live-related donor kidney transplant patients with HIV had equivalent graft and patient longevity, there are still difficulties.
In this particular case, only HIV-positive recipients will be accepted.
HIV-infected organs should only be transplanted from deceased donors with following charachteristics:
HIV <50 copies/mL
CD4 count >200/μL
No history of opportunistic infections in the last 6 months
No history of virological failure or medication resistance
Counseling and informed consent are recommended at listing and transplantation
The transplant center should have HIV+ transplant experience
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
HIV-infected organs should only be transplanted from the following types of deceased donors:
– HIV 50 copies/mL – CD4 count >200/L – No history of opportunistic infections in the previous six months – No history of virological failure or drug resistance
– Counseling and informed consent are advised at the time of listing and transplantation
All HIV transplants follow deceased donor and living donor ethics requirements.
HIV-positive transplant candidates must consent as usual.
Transplant teams must be confident with donor consent and its protocols.
-Recipients should inform donors of their HIV status whenever possible.
Living donors are informed that recipient medical and social information may be preserved.
All living donors must agree that they will not receive confidential recipient information that is not essential to the kidney donation.
Candidates for organ transplants are screened for syphilis, herpes simplex virus, Epstein-Barr virus, cytomegalovirus, varicella zoster virus, human T-cell leukaemia virus, and Toxoplasma gondii.
Transplant candidates are screened for latent Mycobacterium TB infection using an interferon-gamma test with or without a concomitant Mantoux test, in accordance with the testing strategy for immunocompromised patients outlined in the current NICE Tuberculosis Guidelines.
Individuals who are candidates for solid organ transplantation are evaluated for the presence of cervical and/or anal neoplasia; those with advanced cervical/anal intraepithelial neoplasia (CIN/AIN III) or carcinoma in situ should be treated prior to transplantation.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan? Positive flow cytometric cross-match and blood-type incompatibility are contraindications to kidney transplantation in patients with HIV, but FCXM is negative and blood group compatible.
At the time of transplantation, all HIV-positive patients who are eligible for a kidney transplant are administered induction therapy.
Basiliximab is administered to the majority of HIV-positive patients undergoing induction therapy.
After kidney transplantation, HIV-positive patients get triple therapy maintenance immunosuppression consisting of steroids, a CNI, and an antiproliferative drug.
HIV-positive kidney transplant recipients are treated for acute rejection in the same manner as HIV-negative kidney transplant recipients.
-Preemptive switching away from antiretroviral regimens based on boosted protease inhibitors, if alternatives exist, in order to minimize medication interactions.
Will you accept this DBD donor?
For HIV/AIDS patients with advanced organ disease, organ transplantation may be their only chance at extending their lives.
It is advised that only dead donors’ organs with the following characteristics should be used for transplantation utilizing organs from HIV-infected people:
Prior to brain damage, HIV viral load was 50 copies/mL and CD4 count was >200/L for at least 6 months.
Where possible, details about the donor virus’s genetic makeup and current viral burden.
Absence of medication resistance or H/O virological failure.
It is advised that recipients receive counselling and provide informed consent both before being listed and after receiving a transplant.
The transplant centre needs to have knowledge of HIV+ individuals undergoing transplants.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
The HOPE Act also allows people with HIV to be living donors.
Yeah, I will accept him with the aforementioned requirements.
Meet all transplant centre requirements.
Have a CD4 count of more than 500 and an undetectable viral load.
Possess no prior history of an invasive infection, such as current fungal meningitis or PCP pneumonia.
Proceed with a kidney biopsy. Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
In patients with HIV, a positive complement-dependent cytotoxic (CDC) cross-match is an absolute bar to kidney donation; however, a positive flow cytometric cross-match is not (FCXM).
Relative contraindications to kidney transplantation include blood type incompatibility:
Although the presence of DSA shouldn’t stop the transplant surgery, MFI values over 2000 are important and may not be favourably linked with allograft outcomes.
I will discuss it with the patient and let him or her know that due to immune dysregulation, he is immunologically at high risk of being HIV positive.
This is done to rule out co-infection, whether it be HIV/HBV or HIV/HCV, in the recipient.
The ability to perform post-transplant DSA monitoring, biopsies, and other treatment components including routine HIV RNA monitoring, vaccinations, and long-term PCP prophylaxis should be possible.
REFERENCES;
British Transplantation Society Guidelines. Kidney & Pancreas Transplantation in Patients with HIV March 2015 [Minor Revision January 2017]
HOPE Act On November 19 and 21, 2015,
Solid organ transplantation in the HIV-infected patient: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice Emily A Blumberg , Christin C Rogers
Induction therapy
The majority of HIV-positive patients receiving induction therapy are given basiliximab.
HIV-positive kidney transplant recipients receive triple therapy maintenance immunosuppression, consisting of steroids, a CNI, and an antiproliferative drug.
HIV-positive kidney transplant recipients receive the same treatment as HIV-negative recipients.
British Transplantation Society Guidelines. Kidney & Pancreas Transplantation in Patients with HIV March 2015 [Minor Revision January 2017]
I will accept this donor only if the recipient is also HIV positive.
It is recommended that transplantation using organs from HIV-infected individuals is restricted to organs from deceased donors with:
HIV viral load <50 copies/mL
CD4 count >200/μL for at least 6 months prior to brain injury
Information about the donor virus (genotype patterns) where possible & current viral load
Absence of H/O virological failure or drug resistance (1D)
It is recommended that recipients are counselled & give informed consent both at the time of listing & at the time of transplantation (1D)
The transplant center should have experience in transplanting HIV+ patients (Not graded)
=========================== Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes, I will accept him with the same prerequisites mentioned in the scenario above although it is recommended that patients with HIV-infection are unsuitable to be living kidney donors (1D)
Several transplant centers view HIV infection as a medically absolute contraindication to organ donation. However, improvements in HIV patient care, rising waiting times, & reports of organ donation from HIV-positive donors in South Africa who were treatment-naive or just getting first-line ART showing positive results at 3 to 5 years suggest that this strategy should be reexamined.
=========================== Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Screening for HLA-Abs is routine for patients on KTX waiting lists.
In the UK screening is done at least 3 monthly, & HLA antigens to which a patient has detectable Ab are listed as ‘unacceptable mismatches.
Any HLA antigen to which Ab can be identified with an MFI >1000 (by Luminex) is considered undesirable by many units.
This strategy prevents a positive XM after allocation, but it also forbids offering organs to patients with sensitivity issues. However, there are experiences with KTX from DD that was purposefully done in the presence of anti-HLA DSA.
In this scenario, I will proceed with tacrolimus, MMF & prednisolone. Induction with either Basiliximab or Thymoglobulin.
References
British Transplantation Society Guidelines. Kidney & Pancreas Transplantation in Patients with HIV March 2015 [Minor Revision January 2017]
Jolly, E. C.; Taylor, C. J.; Key, T.; Morgan, H.; Peacock, S.; Clatworthy, M. R.; Torpey, N, Deceased Donor HLA Antibody Incompatible Renal Transplantation without Antibody Removal: High Incidence of Acute Rejection Reduced by T-Cell Depleting Induction Therapy
4. You were offered kidneys from a 51-year-old male DBD (donor after brain stem death) donor who suffered from SAH (grade 5) complicating cerebral aneurysm. Her retrieval S Cr was 78 µmol/L. Virology was reported negative for both HBV and HCV, but HIV is positive.
A 51-year-old male DBD donor donated kidneys from SAH-complicating cerebral aneurysm with 78 µmol/L retrieval, negative for HBV, HCV, but HIV is positive..
Yes I will accept this donor
==================================================================== Would you accept this donor as a live donor if the recipient is also HIV positive?
Organ transplants may be the only option to prolong life for HIV/AIDS patientswith end-stage organ disease.
Patients with end-stage renal disease should have a life expectancy of at least five years before transplantation.
HIV-associated nephropathy is the most common cause of ESRD in HIV-infected patients, especially in black patients.
HIV-positive patients on dialysis have improved survival and morbidity,but the complexities of antiretroviral therapy dosing have prompted consideration of renal transplantation.
HIV infection is no longer an absolute contraindication for renal and liver transplants to stable HIV-positive patients.
Graft and patient survival are comparable to non-HIV infected recipients of both cadaveric and live-related donor kidney transplants, but there are still issues to address.
If yes, what are the conditions that should be met?
The HOPE Act also allows with HIV to be living donors. To become an HIV-positive living donor, you must:
Meet all requirements of the transplant center.
Undetectable HIV viraemia (< 50 copies/ml) and CD4 200 cells/microlitre for at least six months.
Demonstrable adherence and a stable HAART regimen for 6 months
Have no prior history of an invasive infection, such as PCP pneumonia or active fungal meningitis.
Undergo a kidney biopsy.
==================================================================== All potential kidney transplant recipients are screened for HIV infection (1D)
• HIV per se is not a contraindication for kidney transplantation (1B)
• HIV-positive patients are wait-listed only if:
a) They are concordant with treatment, particularly cART therapy (1D)
b) Their CD4+ T cell counts are >100 cells/μL (ideally > 200 cells/ μL) and have been stable during the previous 3 months (1B)
c) HIV RNA has been undetectable during the previous 6 months (1B)
d) No opportunistic infections have occurred during the previous 6 months (1B)
e) They have no history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma .
Relative contraindications to kidney transplantation:
a) Positive flow cytometric crossmatch (FCXM) (1D)
b) Blood-type incompatibility (2D)
c) Treated malignancy, including extracutaneous Kaposi sarcoma (2C)
d) Severe and/or uncontrolled medical problems that are unlikely to improve after kidney transplantation and will shorten the patient’s life expectancy (2D)
e) Chronic liver disease (2D)
f) Marked obesity (BMI >35 kg/m 2 ) (2D)
g) HTLV infection (1D
==================================================================== The following should be considered absolute contraindications:
a) Previous or current infections that are at high risk of re-activating with immune suppression:–
• Aspergillus – infection or colonisation
• Any multi-resistant fungal infections
• Cytomegalovirus (CMV) disease with any activity and unresponsive to first line therapy.
• Influenza or RSV infection within 30 days
• Active bacterial infections
• Mycobacterial infections – unless there is clear evidence of successful treatment
b) Advanced cardiopulmonary disease
c) History of neoplasms except solid tumours adequately treated and disease free survival documented for > five years (consult IPTTR pre-listing)
d) HTLV-1 positive patients
e) Patients with significant human papilloma virus (HPV) associated advanced cervical and anal intraepithelial neoplasia (CIN/AIN III) and carcinoma in situ need to be excluded
f) Hepatic cirrhosis (F4 fibrosis by Metavir if HBV/HCV co-infection) and evidence of active viral replication if HBV/HCV co-infected
g) Pregnancy IF female
h) Continuing use of illicit recreational drugs (Recreational drugs include analgesics, depressants, stimulants, and hallucinogens.)
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
The greater incidence of rejection episodes can be explained if (FCXM positivity is a relative contraindication for HIV transplant).
HIV-positive kidney transplant recipients are treated similarly to HIV-negative recipients, with pre-transplant vaccines and post-transplant CMV treatment.
The transplant procedure should not be prevented by the presence of DSA, but MFI values more than 2000 are significant and may not be well correlated with allograft outcomes.
I will counsel the patient about it and inform him or her that he is immunologically at high risk of being HIV positive due to immune dys-regulation. This is done to rule out co-infection in the recipient, whether it be HIV/HBV or HIV/HCV.
I will continue with the transplantation, followed by IL 2RA (Basiliximab) induction and triple immune suppression maintenance (CNIs, MMF, and Prednisolone ).
It should be in order to do post-transplant DSA monitoring, biopsy, and other parts of treatment such routine HIV RNA monitoring, immunizations, and long-term PCP prevention.
O’Leary JG, Kaneku H, Susskind BM, et al. High mean fluorescence intensity donor-specific anti-HLA antibodies associated with chronic rejection Postliver transplant. Am J Transplant. 2011;11(9):1868-1876. doi:10.1111/j.1600-6143.2011.03593.x
Kidney & Pancreas Transplantation in Patients with HIV Compiled by a Working Party of The British Transplantation Society March 2015 [Minor Revision January 2017] Second Edition.
Sawinski D. Kidney Transplantation in Patients with HIV. Kidney360. 2020;1(7):705-711. Published 2020 May 6. doi:10.34067/KID.0002112020
51 years old DBD donor, positive for HIV, and negative hepatitis B and C screen, with normal kidney function. Will you accept this DBD donor?
Yes, I’ll accept this donor to HIV infected recipient after fulfilling the following criteria: Viral load 200/ml or more for at least 6 months before the brain injury. Excluding HIVAN by absence of proteinuria and a kidney biopsy. With continuation of HAART after transplant and the recipient fit for intervention. Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes, I would accept this living HIV donor if he fulfill the following criteria: (HIV Organ Policy Equity Act- 2013) · The viral load is undetectable or less than 50 sopie/ml and CD4> 200 for the last 6 months. · No evidence of HIV associated nephropathy by performing a kidney biopsy, and checking for proteinurea. · Has no evidence of invasive infection, PCP, or active fungal meningitis. · Meet all the requirement of the transplant center.
And the recipient should fulfill the following criteria: · Fit with life expectancy of > 5 yrs · Concordant with HAART therapy (1D) · CD4+ T cell counts are >100 cells/μL (ideally > 200 cells/ μL) and have been stable during the previous 3 months (1B). · Fully HIV RNA load and CD4 > 100 (2C). · HIV RNA undetected or less than 50 copies/ml for the last 6 months (1B). · No history of opportunistic infection for the last 6 months (1B). · No history of PML (Progressive multifocal leukoencephalopathy) , chronic intestinal cryptosporidiosis, or lymphoma (1B).
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan? Yes, I will proceed to transplantation as DSA positive is not a contraindication for transplantation, with this low MFI to A36 – ( found in African) The contraindications are: Absolute: Uncontrolled HIV infection (CD4+ T cell levels persistently < 100 cells/μL during the last 6 months and HIV RNA persistently detectable during the last 3 months) (1C). Non-compliance with anti-retroviral therapy (1D). Serious ongoing or recurring infection, including documented history of PML (1D). Positive CDC crossmatch (1D). Pregnancy (1D). Anti HIV drug resistance and lack of future HIV treatment options (1D). Relative: Positive FCXM (mainly T-cell positive) (1D). ABOi (2D). Treated malignancy, including extra[1]cutaneous Kaposi sarcoma (2C). Chronic liver disease (cirrhosis, chronic HBV or HCV or persistently abnormal liver function testing) (2D). Marked obesity (BMI>35kg/m2) (2D). HTLV infection (due to the risk of developing leukemia) (1D).
References:
(1) Blumberg EA, Rogers CC; American Society of Transplantation Infectious Diseases Community of Practice. Solid organ transplantation in the HIV-infected patient: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13499. doi: 10.1111/ctr.13499. Epub 2019 Apr 21. PMID: 30773688.
(2) BTS kidney and pancreas transplantation in patients with HIV-2017.
1-Will you accept this DBD donor? Yes; I will accept this HIV + deceased Donor after counseling recipient patient. According BTS Guidelines; –HIV per se is not a contraindication for kidney transplantation. (1B)
-Recipients are counselled and give informed consent both at the time of listing and at the time of transplantation. (1D)
-HIV+ organ use is restricted to those centres that have experience in transplanting HIV+ patients. (Not graded)
-Transplantation using organs from HIV-infected individuals is restricted to organs from deceased donors with:
a) HIV viral load < 50 copies/mL and CD4 count > 200/µL for at least 6 months prior to brain injury,
b) Information about the donor virus such as historical genotype patterns where possible and current viral load,
c) No history of virological failure or drug resistance. (1D) 2-Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met? Yes; I will accept this living donor (D+HIV / R+HIV) But if R-HIV, I will not accept this D+HIV According BTS Guidelines; Selection and assessment before transplantation
-Patients with HIV-infection are unsuitable to be living kidney donors. (1D)
-HIV-positive patients are wait-listed only if:
a) They are concordant with treatment, particularly cART therapy. (1D)
b) Their CD4+ T cell counts are >100 cells/µL (ideally > 200 cells/ µL) and have been stable during the previous 3 months. (1B)
c) HIV RNA has been undetectable during the previous 6 months. (1B)
d) No opportunistic infections have occurred during the previous 6 months. (1B)
e) They have no history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma. (1B) Consent and confidentiality;
-Existing guidelines on the ethics of deceased donor and living donor transplantation are followed for all transplantation involving people with HIV disease. (Not graded)
-The standard of consent for HIV-positive transplant candidates is the same as for any other transplant.(Not graded)
-Transplant teams must be satisfied that donor consent is adequate and that procedures for ensuring this are transparent and established in advance. (Not graded)
-Wherever possible, the recipient is encouraged to disclose their diagnosis of HIV to their donor. (Not graded)
-All living donors are asked whether there are any medical conditions that would cause them to change their decision to donate, without highlighting HIV. (Not graded)
-All living donors are made aware that there may be medical and social information about the recipient that is not disclosed. (Not graded)
-All living donors are asked to acknowledge that they are aware that they will not be given confidential information about the recipient which is not deemed relevant to the outcome of the kidney transplant (Not graded) Screening before transplantation;
-All transplant candidates undergo careful immuno-virological and antiretroviral status review. This includes CD4 cell count, HIV RNA level, current and prior antiretroviral therapies, HLA-B5701 status and HIV resistance profile. (1D)
-Patients with HIV RNA levels < 200 copies/mL may be considered suitable for solid organ transplantation if otherwise well and fully adherent with their medications. (1C)
-Transplant candidates undergo serologic testing for syphilis, herpes simplex virus, Epstein-Barr virus, cytomegalovirus, varicella zoster virus, human T-cell leukaemia virus and Toxoplasma gondii. (1D)
-Transplant candidates are tested for latent Mycobacterium tuberculosis infection with an interferon-gamma test with or without a concurrent Mantoux test following the testing strategy for immunocompromised patients in the current NICE Tuberculosis Guidelines. (1C)
-Transplant candidates who test positive for latent Mycobacterium tuberculosis infection are assessed for any evidence of active tuberculosis disease. (1C)
-Transplant candidates with evidence of active tuberculosis disease are treated according to current NICE guidance prior to transplantation. (1C)
-Transplant candidates with latent Mycobacterium tuberculosis infection, in whom active disease has been excluded are treated for latent Mycobacterium tuberculosis infection, according to current NICE TB guidelines, prior to transplantation. (1C)
-All transplant candidates are screened for viral hepatitis. Those found to be hepatitis B surface antigen or hepatitis C antibody positive should have their hepatitis B DNA / hepatitis C RNA levels quantified and be investigated for the presence of liver cirrhosis. (1C)
-All hepatitis B surface antigen positive patients who are wait listed for solid organ transplantation receive treatment to ensure hepatitis B DNA is fully suppressed. (1B)
-Patients considered for solid organ transplantation are assessed for the presence of cervical and/or anal neoplasia; those with advanced cervical/anal intraepithelial neoplasia (CIN/AIN III) or carcinoma in situ should receive treatment prior to transplantation. (1D) Pre-transplant immunization:
-Hepatitis B virus (HBV) vaccine is administered to all non-immune patients (HBV surface antibody titres < 10 mIU/mL). (1B)
-Hepatitis A virus (HAV) vaccine is administered to all non-immune patients. (1D)
-Pneumococcal polysaccharide vaccine (PPV-23) is administered to all patients. (1B)
-Varicella zoster vaccine (VZV) vaccine is administered to non-immune patients with CD4 cell counts >200 cells/µL. (1C)
-Influenza vaccine is administered annually to patients awaiting solid organ transplantation. (1B)
-Diphtheria, tetanus and pertussis (DTP) vaccine is administered to all patients. (2D)
– Measles, mumps and rubella (MMR) vaccine is administered to all patients who are nonimmune to measles. (2D)
-Human papilloma virus (HPV) vaccine is offered to patients at risk of HPV acquisition. (2C) Post-transplant prophylaxis;
-HIV-positive transplant recipients receive lifelong prophylaxis against Pneumocystis pneumonia following transplantation. (1D)
-Prophylaxis against cytomegalovirus is indicated in CMV seronegative recipients of organs from CMV seropositive donors for a minimum of 3 months. (1A)
-CMV seropositive transplant recipients receive either prophylaxis against CMV infection or PCR surveillance and pre-emptive therapy for a minimum of 3 months. (1A)
-Transplant patients who are well and were not assessed and treated for Mycobacterium tuberculosis latent infection or disease before transplantation should be assessed as recommended for patients prior to transplantation. (1C)
-Transplant patients who are well and were assessed and treated for Mycobacterium tuberculosis latent infection or disease before transplantation do not need reassessment for Mycobacterium tuberculosis latent infection unless there is a new history of exposure to tuberculosis. (1C)
-Transplant patients who are re-exposed to tuberculosis after transplantation should be assessed for Mycobacterium tuberculosis latent infection and/or disease as recommended in current NICE TB guidance on tuberculosis contact tracing. (1C)
-Toxoplasma IgG seropositive recipients with a CD4+ count < 200 cells/µL or any recipient of an organ from a donor seropositive for toxoplasmosis receive lifelong prophylaxis. (2C)
-Prophylaxis against Mycobacterium avium complex (MAC) is indicated when the CD4+ ≤ 50 cells/µL, and it be stopped when the CD4 count is >100 cells/µL for 6 months . (2D) Monitoring of HIV virological control;
-Quantitative HIV RNA and CD4+ T-cell counts are measured regularly, with the first assays at 1 month after transplant and subsequent studies every 2-3 months for the first year then every 3-6 months thereafter. (1B)
-If patients have persistent HIV viraemia, drug-resistance testing is carried out to determine treatment options. (1D)
-More frequent monitoring of CD4 count may be necessary in patients receiving depleting antibodies to determine the need for anti-infective prophylaxis. (2D) 3-Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan? –Positive complement-dependent cytotoxic (CDC) cross-match. (1D) is absolute contraindications to kidney transplantation in patients with HIV; But
-Positive flow cytometric cross-match (FCXM). (1D)
-Blood-type incompatibility. (2D) are relative contraindications to kidney transplantation:
And regarding Induction and maintenance immunosuppression will follow (BTS Guidelines)
-All HIV-positive patients eligible for kidney transplantation are offered induction therapy at the time of transplantation. (1C)
-For the majority of HIV-positive patients induction therapy is with an interleukin-2 receptor antagonist (IL-2RA). (1B)
-HIV-positive patients are given triple therapy maintenance immunosuppression started at the time of kidney transplantation, including steroids, a calcineurin inhibitor (CNI) and an anti-proliferative agent. (1C)
-Acute rejection is treated in HIV-positive kidney transplant recipients in the same way as HIV-negative kidney transplant recipients. (2D)
-Pre-emptive switching away from boosted protease-inhibitors (PI)-based antiretroviral regimens, if alternatives exist, in order to minimise drug interactions. (2D)
-Antiretrovirals with nephrotoxic potential (specific tenofovir formulations and atazanavir) are avoided in the setting of kidney transplantation if suitable alternatives are available. (Not graded)
-Antiretrovirals with significant drug-drug interactions with calcineurin inhibitors (ritonavir and cobicistat) are avoided in the setting of solid organ transplantation if suitable alternatives are available. (2D) References;
British Transplantation Society Guidelines;March 2015 [Minor Revision January 2017].
This is not a focused answer, just a copy and paste from the guidelines. Please answer the questions asked above in. You are hitting a fly with a cannon ball.
Thanks, our Prof and sorry for details. Q1;
Yes; I will accept this HIV + deceased Donor after counseling recipient patient. Q2;
Yes; I will accept this living donor (D+HIV / R+HIV) and to R/O D+ HIV AN by kidney biopsy.
But if R-HIV, I will not accept this D+HIV Q3;I will give induction an interleukin-2 receptor antagonist (IL-2RA) & maintenance protocol as triple therapy immunosuppression started at the time of kidney transplantation, including steroids, a calcineurin inhibitor (CNI) and an anti-proliferative agent.
and keep in mind drug interaction between HAART & CNI,
If the recipient is HIV positive , then donation from HIV positive donor is advised and recommended as per National kidney foundation Hope Act made on 2013. Its recommended to have lower HIV viral load and CD4 count more than 500 in the cadaveric donor . However, no cut off value is clearly indicative for selection.
According to the same Hope Act living donation is possible to an HIV positive recipient. Conditions for accepting HIV living organs donation:
1]maintaining the standards of transplant center.
2]Viral load has to be undetectable
3] C4D count exceeds 500.
4] Negative past history of invasive infection such as PCP pneumonia and fungal meningitis . Recipient with DSA against A36 with MFI of 1550: As far as FCXM is negative , There is minimal risk of acute rejection and hyperacute rejection. However pre-formed DSAs titer has to be followed up regularly along with allograft function. Additionally, characterization of IgG DSAs might be considered , with C1q test to assess for complement fixing property and IgG analysis to identify subtypes .
Anti rejection must be optimized with ATG induction and Tacrolimus based maintenance protocol.
References:
1] National Kidney foundation. HIV and Kidney Transplantation/Donation. 2]Peter S. Yoo et al. Clinical outcomes among renal transplant recipients with pre-transplant weakly-reactive donor specific antibodies.Clin Transplant. 2014 Jan; 28(1): 127–133.
Thank you, Wael Agree with the kidney biopsy, but do you still give ATG just because of the DSA while crossmatch is negative? Remember, there is no strong evidence. It is a high-risk transplant. Which one is more important, a functioning kidney or a patient dying from infection?
Yes, provided that his recipient is HIV positive as well, otherwise I wouldn’t due to ethical and legal concerns. First we need to confirm the diagnoses of HIV in the stored donor sample if possible to rule out false positive results. If it is confirmed positive, then the bases of accepting this donor will be: his viral load < 50 and CD4 > 200 over the last 6 months before the brain death, information about historical genotype pattern were available, and history of virologic failure or drug resistance. The recipient must be having stable disease at least over the last 6 months with good compliance, viral suppression, CD4 > 200, and no opportunistic infections or malignancies.
Q2.
Yes, liver disease is the third leading cause of death in HIV patients and patients with HIV are at risk of end-stage liver disease due to co-infection with HCV/HBV, drug induced, alcohol & non-HIV related factors. The recipient with co-infections e.g., HBV must be given antiviral therapy to the suppress HBV and may be given HBV IVIG during transplantation. For HCV in this era of DAA therapy the patient can be treated easily before transplantation. Exclude advanced CKD before to proceed, and as mention before the recipient must be having stable disease at least over the last 6 months with good compliance, viral suppression, CD4 > 200, and no opportunistic infections or malignancies.
Q3.
The most important is that the FCXM is negative
The presence of DSA per se should not preclude the transplants process
The MFI cut off varies between laboratories but according to UNOS, MFI > 3000 is significant and MFI is really not a quantitative assay. MFI vaules may not correlate well with allograft outcomes
Take history of sensitization e.g., blood transfusion, pregnancy & previous transplant
DSA may wave and wane
I will repeat it again before transplantation
I will at the HLA mismatch, ABO compatibility
We need to rule out co-infection in the recipient HIV/HBV or HIV/HCV
I will counsel the patient about it, and tell him/her anyway he/she is immunologically at high risk being HIV positive due to immune dys-regulation. Infection risk may go up, DGF, & risk of rejection is 2 to 3 time > non-HIV individual. Overall , transplantation is far better than being on dialysis.
I will proceed to transplantation, induction by IL 2RA (basiliximab) and maintenance by triple immune suppression (CNIs, MMF, and PRED)
Post transplant monitoring for DSA specially in the first 3 months
In case of suspicion of rejection, we will go for biopsy and manage him according to the general population guidelines
Other aspects of care such as monitoring of the HIV RNA per protocol, vaccinations and long-life prophylaxis against PCP should be in order.
Source:
-BTS guidelines 2018
-Organ transplantation in persons with HIV by Rebecca N. Kumar and Valentina Stosor
Thank you, Ben Agree with your management plan. I would not give ATG or perform desensitisation in an HIV patient with negative crossmatch. I rather monitor and see what happens.
Will you accept this DBD donor? Yes, I would accept this HIC positive donor only if the recipient is also HIV positive.
Transplantation using organs from HIV-infected individuals is restricted to organs from deceased donors with:
HIV viral load <50 copies/mL and CD4 count >200/µL for at least 6 months prior to brain injury
Information about the donor virus such as historical genotype patterns where possible and current viral load
No history of virological failure or drug resistance
Recipients are counselled and give informed consent both at the time of listing and at the time of transplantation
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
BTS guidelines say:
“Patients with HIV-infection are unsuitable to be living kidney donors”
While there are many reports on HIV+ve to HIV+ve transplant.
The HIV+ve living donor can be accepted for HIV+ve recipient if :
When evaluating potential candidates for donor nephrectomy, the assessment must include identification HIV-specific risk factors for development of ESRD such as low CD4 cell count and HCV coinfection in addition to other conditions that generally exclude persons from donation (e.g. diabetes mellitus, hypertension, and preexisting kidney disease)
HIV African American persons with high-risk apoprotein L1 (APOL1) genotypes are at risk for development HIVAN and focal segmental glomerulosclerosis
The problem with HIV+ve to HIV+ve transplant is superinfection with the donor HIV strain, including acquisition of CXCR4-tropic or dual/mixed-tropic virus or transmitted antiviral resistance.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
If the potential recipient has DSA (A36 with MFI 1550), FCXM negative, then the decision of taking the risk on transplant in such setting will depend on the sensitization status of the recipient, how long can the recipient wait till next suitable donor, risks on being dialysis versus accepting such transplant.
If FCXM is negative(FCXM positive is relative contraindication for HIV transplant), then the donor can be accepted, explaining the higher risk of rejection episodes.
The MFI values are also less than 2000.
Induction can be by interleukin-2 receptor antagonist (IL-2RA)
Maintenance by triple immunosuppression
Acute rejection is treated in HIV-positive kidney transplant recipients in the same way as HIV-negative kidney transplant recipients
Consider for pre-transplantation vaccinations and post-transplant prophylaxis against Pneumocystis pneumonia, CMV (depending upon the status)
BTS guidlines: Kidney & Pancreas Transplantation in Patients with HIV
Thank you, Abhijit Agree with your management plan. I would not give ATG or perform desensitisation in an HIV patient with negative crossmatch. I rather monitor and see what happens.
2- yes will accept in the following conditions:
a- on ART
b-CD4 count more than 100 or 200 with stability over the previous 3 months
c-PCR HIV less than 50 copies per ml stable over previous 6 months
d-no history of opportunistic infections in the last 6 months
e-no history of PML, chronic intestinal cryptosporidiosis or lymphoma
i- as regard donor, should search for any factors leads to CKD like DM, HTN, HIVAN, FSGS.
3-i think the plan will be induction by basiliximab, maintenance by tacrolimus, MMF, and prednisolone
Yes, I will accept this DBD if the recipient is HIV +
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Though live donation was absolutely contraindicated due to the risk of CKD, the ability to use them will make more organs available and reduce the waiting list. However, another important concern is that a limited number of cases have been done which makes it more difficult to have a holistic view of the outcome of such a procedure
Yes if the following criteria are met
CD4 count that is greater than 200cells/mol
Undetected HIV viral load
Exclude HIVAN by kidney biopsy for histology
Absence of proteinuria
If the recipient is a black African-American, particularly from west Africa, APOL 1 mutation must be absent before accepting the graft
Absence of other comorbidities like DM or hypertension
Counsel recipient and obtained informed consent both at the time of listing and before the transplantation
The surgery must be done at a center with good experience in HIV kidney transplantation
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
A36 is largely limited to Africa. Outside Africa, more than half of the population have no A36 and the majority that do, have only trace levels.
MFI 1550 level is usually center specific in which different transplant centers have their different cut level for desensitization to be done for the recipient. At the center, I used to work in Nigeria, our cut-off is >1000 MFI and hence I will manage as follows
Check for other virus-like HBV, HCV
Baseline LFT level
Check latent TB with IGRA
I will offer the patient one session of plasmapheresis with IVIG
Ensure HAART medications are taken after plasmapheresis
The induction will be done with rATG for 3 – 7 days
Avoidance of PI as part of HAART medication
Maintenance drugs will be CNI, MMF, and prednisolone
prophylaxis for CMV, and PJP
BK virus level at 3 months post-KTP
HIV viral load check after one month, then every 3- months in the first year
The usual routine kidney function test, LFT for follow up
References
Rebecca N. Kumara, Valentina Stosor. Organ transplantation in persons with HIV. AIDS. 2020, 1107- 1116.
HIV and Kidney Transplantation. By Ahmed Halawa
BTS. Kidney and Pancreas Transplantation in Patients with HV. Second Edition.
· Will you accept this DBD donor?
Yes will accept if the recipient is HIV + and has;
· CD4 count is more than 200 cell/micoL.[1]
· Undetectable viral load.[1]
· On ART for at least six months
· No history of CNS Lymphoma, PML and Kaposi sarcoma.
· Patient counseling regarding integrase inhibitor- based ART regimen due to PI with effects on CYP3A4.
· Allograft function monitoring
· HIV viral Load monitoring at one month an every 3rd month.
· Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
In addition to above mentioned points in recipient, will have to exclude HIVAN or HIVIC in donor before donation, so all HIV donors must have kidney biopsy in addition to;
· must have a CD4 count of >500 cells/microL,
· and HIV viral load <20 copies/mL
· On ART for at least 6 months.
· Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
There is no consensus on the agent used for induction in HIV recipients but antibody ( rATG OR IL-2 receptor) compared to no induction has lower risk of DGF and graft loss.[2] However antibody induction didn’t reduced risk of acute rejection. Antibody therapy is not associated with increased risk of infection as well.
References
1. Stock PG, Barin B, Murphy B, et al. Outcomes of kidney transplantation in HIV-infected recipients [published correction appears in N Engl J Med. 2011 Mar 17;364(11):1082]. N Engl J Med. 2010;363(21):2004-2014. doi:10.1056/NEJMoa1001197 2. Kucirka LM, Durand CM, Bae S, et al. Induction Immunosuppression and Clinical Outcomes in Kidney Transplant Recipients Infected With Human Immunodeficiency Virus. Am J Transplant. 2016;16(8):2368-2376. doi:10.1111/ajt.13840
Thank you, Faraman Will you still give ATG even with a negative crossmatch? Have you excluded HIVAN in the donor? Please go back to what we have taught you in modules 1 and 2.
Yes professor, I highlighted “all HIV donor must have kidney biopsy”
Regarding induction antibody therapy is better than no antibody so in this case I will prefer IL 2 Rather rATG
To increase the the donor pool recently and under some conditions we can accept this DBD donor.
A) HIV viral load <50 copies/mL and CD4 count >200/µL for at least 6 months prior to brain injury
b) Information about the donor virus such as historical genotype patterns where possible and current viral load
c) No history of virological failure or drug resistance
● Recipients are counselled and give informed consent both at the time of listing and at the time of transplantation
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
● Patients with HIV-infection are unsuitable to be living kidney donors. However, some recent trials have reported optimistic results
for example; HIV-Positive–to–HIV-Positive Kidney Transplantation — Results at 3 to 5 Years study. performed four renal transplantations in HIV-positive recipients using kidneys from HIV-infected donors. The preliminary results from that study showed 100% graft survival and patient survival at 1 year.
the conditions that should be met
for donor ■no sepsis ■No activeTB ■ NO WHO stage 4 HIV
■ NO PROTEINURIA
■ Undetectable plasma RNA Load (less than 50 copies/ml)
For recipient
○use of antiviral treatment for more than 3months
○CD4 t cell less than 200
○undetectable plasma RNA HIV load
This type of transplantation need expertise transplantat center
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
In this case FCXM is neg we can accept the donor for HIV Recipient. However , we need an appropriate management
For most patients with (pos DSA) and (neg FCXM ), treatment with (IVIG) can prevent of rejection.
ATG and HIV;
●Limited studies using ATG in HIV pos recipients
●Previous guidelines recommended against.
●recently, there have been reports of successful use in HIV-positive recipients, however associated with reduced CD4 count without increased incidence of opportunistic infection, progression to AIDS or death, but may be associated with reduced graft survival.
●For the majority of HIV pos patients induction therapy is with (IL-2RA), but it may not appropriate in this case
●we should remember that Rituximab may cause leukopenia, late-onset neutropenia and decline of CD4+ and CD8+ T-cell counts.
●Antiviral treatment interacts with immunosuppression maintenance treatmen (TAC – MMF- PRED) , Therefore we should close monitoring the level of TAC and others
REFERENCES
1- Professor Halawa lecture
2 – Kidney & Pancreas Transplantation in Patients with HIV (BTS)
5- Preexisting Donor Specific Antibody (DSA) with a Negative Flow Crossmatch (FCXM) Should Not Preclude Kidney TransplantationV. Kumar, V. Hauptfeld-Dolejsek, A. Kamal Abdelkader, J. Goodman, J. Locke, R. Gaston
University of Alabama at Birmingham, Birmingham. Meeting 2013 American Transplant Congress
Will you accept this DBD donor?
Yes, would you accept the transplant if:
1. Sustained negative viral load (< 50 copies) in the last six months
2. No history of opportunistic diseases in the last six months
3. No history of PLE, Lymphoma or intestinal Cryptosporidium
4. Serum CD4 greater than 200 cells
5. HAART sensitivity profile, prioritizing the use of integrase inhibitors (dolutegravir) and avoiding nephrotoxic drugs (protease inhibitors and Tenofovir).
Induction with Basiliximab (IL2R blocker) is considered the best option because would be less interference with CD4 levels.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
It is a situation that depends a lot on local criteria and ethical issues to be discussed. Both donor and recipient must be aware of this situation and a thorough study of the donor would be necessary, prioritizing the profile of resistance to HIV and the discussions that we placed in the previous topic.
If both donor and recipient have the same profile of sensitivity to antiretroviral drugs, it is possible to prioritize a scheme with Dolutegravir and avoid nephrotoxic drugs.
If the donor has a resistance scheme, either due to failure, abandonment or previous exposure, he would not proceed with the transplant. Alternative regimens for HIV control require combinations of integrase inhibitors with additional drugs to transcriptase inhibitors, decreasing their response and increasing drug interactions with other drugs, mainly immunosuppressants such as calcineurin inhibitors.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
In this case, induction should be performed with rATG, avoiding Basiliximab.
Monitoring should be very close, as it decreases CD4 lymphocyte activity and can induce AIDS and opportunistic infectious diseases. In this case, lifelong prophylaxis for Pneumocystosis is considered.
We do not have Belatacept in our service, but your indication should be considered and individualized.
Calcineurin inhibitors should be measured frequently and scheduled graft biopsies may be required to minimize the risk of graft rejection.
Thank you, Filipe Will you still give ATG even with a negative crossmatch? Have you excluded HIVAN in the donor? Please go back to what we have taught you in modules 1 and 2.
Sorry, Professor. That is true.
I was worried about a deceased donor with DSA positive.
We do not have basiliximab at Brazil, so that was the motive to talk about rATG.
If the recipient is HIV positive, I will accept the donor with the following recommendation:
a) HIV viral load <50 copies/mL and CD4 count >200/μL for at least 6 months prior to brain damage b) Details regarding the donor virus, including history genotyping trends and current viral load.
b) No virological failure or drug resistance.
• Listers and transplanters are counseled and obtain informed consent
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
I will not accept a living donor who is HIV positive, because of the very limited data available.
HIV-to-HIV live donor transplantation has been recorded rarely. HIV-specific risk factors for ESRD, such as low CD4 cell count and HCV coinfection, must be identified in donor nephrectomy candidates.
HIV-positive African Americans with high-risk apoprotein L1 (APOL1) genotypes are at risk for HIVAN and focal segmental glomerulosclerosis, although it is unclear whether APOL1 haplotype screening is useful. HIV-positive donors should avoid nephrotoxic ART such as tenofovir and nonsteroidal anti-inflammatory drugs after nephrectomy.
Only two live donor kidney transplants have been documented, one with favorable long-term results for both donor and recipient.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Induction therapy is provided to all HIV-positive patients who are eligible for KTX. Most HIV patients induction with IL2 R
but in this case: Induction therapy is with ATG(+ve DSA)
• HIV+ individuals are given triple therapy maintenance IS (steroids, a CNI, & an anti-proliferative drug).
References: Kumar, R. N., & Stosor, V. (2020). Organ transplantation in persons with HIV/AIDS (AIDS, 34(8), 1107–1116).
Kidney & PancreasTransplantation in Patients with HIV
-Until 2013 it was against federal regulation to transplant organs from someone who was HIV+ into a potential organ recipient, even if the intended organ recipient was also HIV+. However, in 2013 these HIV prohibitions were determined by Congress to be outdated. The HOPE Act directed the Health and Human Services (HHS) Secretary to develop guidelines to conduct research relating to HIV+ donors and organ transplantation to HIV+ve recipients . -I will accept this DBD HIV+ve donor for a an HIV+ve recipient of course .
-In patients with HIV and ESKD , renal Tx has been associated with survival benefits although having a higher risk of rejection due to : -Interaction between CNI’s and protease inhibitors(PI) may lead to subtherapeutic levels.
-rATG is feared so IL-2i are used instead which may increase the acute rejection risk .
-Patients must have an undetectable viral load and a CD4 count >200 cells/micL on a stable ART regimen for at least 6 months .
-Before the Tx , the ART regimen should be switched to a regimen that doesn’t include a protease inhibitor -(integrase inhibitors are preferred ) if possible .
-The use of induction IS with HIV remains controversial ;many centers prefer Basiliximab over rATG in HIV+ve individuals .
-If the potential recipient has DSA (A36 with MFI 1550), but negative FCXM , i will still accept this donlor , no desenstization , induction by rATG over basiliximab in this case ( but possibly lower doses) , steroids , Tacrolimus and MMF .
Refrences : 1-Up-to-date HIV and renal transplantation 2- Prof.Dr.Ahmed halawa’s lecture
Thank you, Mohamed Will you still give ATG even with a negative crossmatch? Have you excluded HIVAN in the donor? Please go back to what we have taught you in module 1 and 2.
Yes ,as per BTS guideline.
Condition to be met.
Compliant to ART.
CD4 more than 200cell for 3months.
Viral copies less than 50 copies for 6months’
No history of opportunistic infection.
No proteinuria in donor or history of HIVAN.
Yes there no contraindication. with negatives FCM.
Follow up is needed
Q. 1, Will you accept this DBD donor?
Yes, I will accept the donation.
Q. 2,
Yes, I will accept, according literature demonstrated that this allograft can be accepted with HIV, if copies <50 and CD4+T >200 for more then six months.
However,
there is possibility of higher risk of rejection, secondary to drug toxicity,
and interaction.
Q. 3,
There are certain criteria before to proceed for transplantation.
Like,
Donor should not have HIVAN.
May be biopsy necessary,
HIV copies should be <50.
CD4+ T cell should be >200cells/ul.
No opportunistic infection currently.
Recipient should be stable for at least 3 to 6 months.
No chronic infection, and malignancy.
Q. 4,
There is no contraindication for transplantation
However, surveillance biopsy and follow up test mandatory.
Induction with basiliximab, maintenance medication with lower dose compare to others.
References;
1.Alameddine
M, Jue J, et al. Challenges of kidney transplantation in HIV positive
recipients. Transpl Androl Urol, 2019;
8(2) : 148-154. doi: 10.21037/tau.2018.11.09.
2. https://www.uptodate.com/contents/kidney-transplantation-in-adults-kidney-transplantation-in-patients-with-hiv?search=HIV%20and%20renal%20transplantation&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.
HIV-positive donor to HIV-positive recipient (HIV D+/R+) transplantation is permitted in the United States under the HIV Organ Policy Equity Act. To explore safety and the risk attributable to an HIV+ donor, we performed a prospective multicenter pilot study comparing HIV D+/R+ vs HIV-negative donor to HIV+ recipient (HIV D-/R+) kidney transplantation (KT)
overall transplant and HIV outcomes were excellent; a trend toward higher rejection with D+ raises concerns that merit further investigation.
https://pubmed.ncbi.nlm.nih.gov/32701209/
Will you accept this DBD donor?
· Yes, I will accept this deceased donor (for HIV recipient) if donor’s kidney biopsy doesn’t show HIVAN.
The donor should meet the following criteria:
1. The HIV viral load <50 copies/mL
2. The CD4 count >200/µL for at least 6 months before his brain injury
3. No evidence of proteinuria
4. No evidence of HIV-AN in preemptive kidney biopsy
5. No history of drug resistance or opportunistic infections
· This recipient should receive proper counseling regarding the risk of transmission of other HIV strains and opportunistic infections before proceeding with transplantation.
· Anti-retro-virals with significant drug interaction with tacrolimus should be changed prior to transplant.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
The HIV infected donor is unsuitable for living kidney donation as per BTS guidelines(2017).However, living kidney donation from HIV+ donor to HIV + recipient can be accepted as per HIV Organ Policy Equity Act 2013(HOPE 2013) if the donor and recipient full certain criteria:
Donor criteria:
· The HIV viral load <50 copies/mL
· The CD4 count >200/µL for at least 6 months before his brain injury
· No evidence of proteinuria
· No evidence of HIV-AN in preemptive kidney biopsy
· No history of drug resistance or opportunistic infections
Recipient criteria:
· Undetectable HIV viral load (< than 50 copies/ml for the 6 months prior to transplant.
· stable CD4 count above 100 cells/ul during the 3 months before transplant
· Expected life survival> 5 years.
· Compliant on HAART.
· No history of opportunistic infection for the 6 months before transplant.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
· I will accept this recipient with negative FCXM negative. The presence of DSA against A36 with low MFI 1550 carries low risk of hyper-acute rejection. There is no need for any desensitization prior to transplantation.
· Immunosuppression:
· Induction regimen: The IL-2 R anatagonist Basiliximab is preferred over the lymphocyte depleting agents like ATG and Almetuzumab in HIV positive recipients.
Maintenance: Triple Immunosuppression :steroids+TAC +MMF.
Post-transplant prophylaxis against PJP and CMV as per guidelines.
Monitor drug levels, kidney function test., and DSA level.
· Post-transplant prophylaxis for PJP and CMV is required.
· Post-transplant monitoring of HIV RNA and CD4 count in the first month, then every 2-3 months till the end of the first year, then 3-6 monthly thereafter.
· Post-transplant DSA follow up and possibly protocol-biopsy as per center protocol.
References:
Will you accept this DBD donor?
Yes I will accept him only for HIV infected recipient.
After the introduction of ART, several studies have demonstrated comparable patient and graft outcomes between HIV-negative and HIV-positive kidney recipients.
Would you accept this donor as a live donor if the recipient is also HIV positive?
Yes I will.
HIV-infected living donation was permitted under the HOPE Act., with a major concern regarding the safety of kidney donation in an HIV-infected person du e to risk of renal disease associated with HIV infection.
For HIV infected recipient in the past there were higher rate of rejection which was multifactorial and includes the significant drug-drug interactions between CNIs and PIs or older generations of non-nucleotide reverse transcriptase inhibitors that can often lead to subtherapeutic level of immunosuppressive agents.
recent advances in the HIV medications, especially after the introduction of the integrase inhibitors avoided this problem.
if yes, what are the conditions that should be met?
-Donor must be under treatment for the last 6 months with Undetectable HIV viremia (< 50 copies/ml).
CD4 more than 200 cells for at least six months.
– a kidney biopsy must be done before TX to ensure absence if HIVAN.
– both donor and recipient must continue and of HAART after transplant .
– no history of invasive infection, PCP, viral , or fungal meningitis.
– Recipient must has CD4+ T cell counts are >100 cells/μL (ideally > 200 cells/ μL) and have been stable during the previous 3 months, HIV RNA has been undetectable during the previous 6 months, No opportunistic infections such as active CMV , no malignancy.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Negative FCXM is not a risk of rejection even in presence of DSA with MFI level not sufficient to cause positive crossmatch ( MFI 1550) so no contraindication for RX .
Follow up of dsa and protocol biopsy early after TX is mandatory due to immune system dysregulation and he must be informed about potential risk of AMR.
Reference
Ayelet Grupper 1 2, Yaacov Goykhman 1 2, Roni Baruch .In sickness and in health: Living HIV positive kidney donation from a wife to her husband, with 7 years’ post-transplant follow-up. 2019 Dec;21(6):e13171.
Yes, i would accept this DBD donor to increase donor pool & if following conditions are met
– HIV viral load <50 copies/ml and CD4 count >200/ul for at least 6 month prior to brain injury
– Information about the donor virus such as historical genotype patterns where possible and current viral load.
– No history of virological failure or drug resistance.
Recipient are councelled and give informed consent both at the time of listing and at the the time of transplantation
Paients with HIV-infection are unsuitable to be living kidney donor.
I could accept this donor as a live donor if following conditions are met:
For Donor:
– No sepsis
– No active TB
– HIV RNA < 50 copies/ml.
– No proteinuria and exclusion of HIVAN
For Recipient:
– On antiviral treatmen for at least 3 month
– No detectable HIV RNA
– CD4>200/ul
– Induction therapy with basiliximab( NO ATG)
– Tacrolimus based tripple therapy
Scenario- HIV-positive donor with negative Hepatitis B and C
Will you accept this DBD donor?
No, unless the recipient is HIV positive
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes, however the recipient need to have
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
This patient has low-level HLA-DSA, careful assessment and explanation are important prior to donation (risk of hyperacute rejection)
Reference
Q1: Yes, if the recipient is HIV positive, I will agree.
The HIV- negative recipients are not permitted to receive kidney from HIV-positive donors. The patient can donate kidney, if viral load is less than 50 and CD4 is above 200 during the last six-months. Negative history of drug resistance or genotype pattern are important to determine before donation.
The recipient should have no active infection or malignancy and be stable considering the above mentioned condition.
Q2: Yes, I will accept, if the donor’s kidney is not affected by HIV with no proteinuria and even normal kidney biopsy. The other conditions as mentioned above, should be met, as well.
Q3: I will proceed the transplantation, because FCXM is negative. DSA monitoring after TX should be performed.
In this situation, induction therapy with basiliximab should be considered and continue with the triple maintenance therapy. ATG is not logical, because of high risk of opportunistic infections.
Reference:
Blumberg, E. A., & Rogers, C. C. (2019). Solid organ transplantation in the HIV-infected patient: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clinical Transplantation, 33(9). https://doi.org/10.1111/ctr.13499
The donor is a deceased donor after brain death with good renal function….The donor is negative for HBV and HCV, but the donor is positive for HIV….
As per the HIV organ policy equity act permits HIV +ve donor to register as donors….They should be denied about their rights to donate their organs….The recipients as per the BTS guidelines in the HOPE act should be HIV positive…HIV positive organ donation to HIV negative recipients are not yet approved…
the donor should not have had history of virological resistance..The donor before donation should have a urine examination to rule out HIVAN
The other conditions that must be met before organ registration in HIV donors are that donor CD4 >200 and HIV RNA < 50 in last 6 out of 12 months…
So this organ can be given to HIV Positive recipient
Live donor with HIV positive status…
Personally It is best avoid kidney donation in donors with HIV.. due to the life long morbid nature of the disease…they are at risk of HIVAN and other complications due to the HAART and opportunistic infections…BTS recommends against kidney donation in HIV donors…If no other options are available for both donors and recipient they should be evaluated in detail
The donor and recipient should be on HAART and should have suppressed HIV Viral load in last 3 months….CD4 count >200 cells or atleast more than 100 cells in the last months…..
Both donor and recipient should be screened for HIVAN and if there is HIVAN in the donor the proceeding should be stopped….The donor and recipient should be screened for opportunistic infection namely latent TB as per NICE guidelines…They should not have history of lymphoma, PML or cryptosporidiosis…they both should not have history of HIV resistance….
If the potential recipient has DSA (A36 with MFI 1550), but a negative FCXM….. The low MFI value, the patient maybe taken up for transplant if all other donor and recipient criteria for HIV are met as mentioned above….We have use IL2 receptor antagonists as induction agent due to increased risk of infection and malignancy…standard maintenance.. with triple immunosuppression is needed ..Regular monitoring of DSA is recommended post transplant …We need to do renal biopsy if there is raising titres of DSA…We have to check CD4 count every month after transplant for 3 months and then monitor once in 3 months after renal transplant…Anti retrovirals should be given that have less enzymatic interaction and can be used post transplant….
No, donations for HIV D+/R- are not released yet, although there are feasibility studies for this situation.
In this hypothetical situation, if the recipient is also positive, he would accept the organ.
It would be necessary to fulfill the requirements of controlled viral load, CD4 > 200 copies and absence of opportunistic diseases
This DAS value is low, with no risk of acute rejection and no indication of stronger suppression induction.
Since there is no risk of acute hyperrejection, I would avoid induction with ATB and use corticosteroids with basiliximab and maintain the patient’s HIV ART treatment.
Will you accept this DBD donor?
The donor with HIV can be accepted in transplantation when:
HIV RNA less than 50 copies and CD4 is more than 200 in the last 6 months prior to brain injury
No drug resistance
Would you accept donor as live donor if recipient is also HIV positive? If yes what conditions should be met?
Yes, I will accept in case of:
HIV RNA is suppressed and CD4 more than 200
No infection
No HIV related nephropathy for the donor
If potential recipient has DSA(A36 with MFI 1550),but neg FCXM, what would be the mgt?
Low DSA level with low risk of rejection
Induction by basiliximab
Maintenance: CNI, MMF , steroid
Monitor DSA
1. Will you accept this DBD donor?
Yes, HIV positive deceases donors are accepted, as per HOPE Act, after exclusion of HIVAN.
Using organs from HIV-infected individuals is restricted to organs from deceased donors with:
– HIV viral load <50 copies/mL and CD4 count >200/µL for at least 6 months prior to brain injury
– Information about the donor virus such as historical genotype patterns where
possible and current viral load
– No history of virological failure or drug resistance
Recipients are counselled and given informed consent about the donor serostatus, need for ART and monitoring.
2. Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
As per BTS guideline
· We recommend that patients with HIV-infection are unsuitable to be living kidney donors (1D)
· We suggest that HIV+ organ use is restricted to those centres that have experience in transplanting HIV+ patients (Not graded)
Although very few cases of HIV-to-HIV living donor transplantation are reported,
personally, I would discourage organ donation from HIV-infected live donor, due to the high incidence of HIVAN and risk of CKD in HIV population, which might put them at higher risk of ESRD and death after kidney donation.
If there is no alternate donor and the donor insists to donate to that particular HIV+ recipients, the following criteria have to be met:
· Both donor and recipients should be screened for TB (Mx, IGRA/ QuantiFERON-TB Gold) LTBI and active TB, and if found, to have completed treatment as per NICE guidelines.
· The potential donor should be assessed for HIV-RNA viral load, CD4+T-cell count and HCV coinfection, in addition to other conditions that preclude donation (DM, HTN, and pre-existing kidney disease)
· HIV+ African American persons with apoprotein L1 (APOL1) genotypes are at high risk for the development of HIVAN and FSGS.
· Post-kidney donation, HIV+ donors should avoid nephrotoxic ART (such as tenofovir), NSAID, other nephrotoxic drugs.
3. Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
FCXM negative, DSA is positive, although not so high.
· We have seen hyperacute rejections (in as many as 4 occasions) with such level of DSA (done on NGS- complete panel) in spite of T&B cell X match (both CDC and FCXM) negative.
· HIV+ recipients being high immunological risk (30% risk of rejection), high DSA h would put the recipient at higher risk of rejection (especially ABMR).
– So, I would prefer desensitization with 1 plasma exchange + IVIg 10 gram to minimize the risk of accelerated ABMR.
· Induction Agent: T-cell depleting agent (Thymoglobulin) should be avoided in HIV positive recipients, although >30% of recipients in different studies have received Thymo-induction, without much complications (except lower CD4 cell count).
· But this index case being high immunological risk, Thymoglobulin can be used, to prevent ACR. It will need frequent monitoring of CD4-Tcell count and surveillance for opportunistic infections.
· Maintenance immunosuppression – triple drug regimen (Tacrolimus, Mycophenolate, and prednisone) as per guidelines to be used.
· HAART needs to be continued immediately post-op after patient starts oral diet – Tenofovir should be replaced with other drugs.
· Post-transplant, lifelong prophylaxis for pneumocystis jirovecii should be given. CMV prophylaxis for minimum 3 months for D+/R- pair and Toxoplasma prophylaxis if donor seropositivity should be given.
· HIV RNA and CD4 count should be monitored at 1 month, and then every 2-3 months till 12 months, and then 3-6 monthly.
· RFT and Tac C0 level needs to be monitored frequently, as CNI level fluctuate (may be low / very high) due to drug-interaction of ART with IS.
Regarding induction agent – I would prefer Thymoglobulin, as the index case is candidate of high risk of rejection.
Kidney transplant recipients with HIV have a high frequency of rejection. In a large, multicentre trial, 1and 3 years’ rejection rates were 31% and 41% respectively, compared to expected one-year rejection rate of 12%.
There is a controversy regarding induction of IS – some use basiliximab (IL-2 RA) based on data from kidney transplant in recipients with HIV, that demonstrated an increased risk of infection among those treated with rATG-Thymoglobulin . Other centers prefer to use rATG-Thymoglobulin given its superior efficacy in preventing acute rejection in recipients without HIV.
Post-transplant monitoring of DSA and a protocol biopsy at 3 months should be done. Presence of ABMR on biopsy, needs treatment with Plasma Exchange + IVIg (+/- Retuximab). If DSA is increasing, IS should not be reduced. If the DSA is not increasing, and there is no ABMR, then follow-up DSA level should be tested at 12 months and whenever there is any significant change in immunosuppression, graft dysfunction, or suspected non-adherence.
References:
1. British Transplantation Society Guidelines 2017. Kidney & Pancreas Transplantation in Patients with HIV
2. Kumara N, Rebecca, Stosor V. Organ transplantation in persons with HIV. AIDS 2020, 34:1107–1116
3. Stock PG, Barin B, Murphy B, et al. Outcomes of kidney transplantation in HIV-infected recipients. N Engl J Med 2010; 363:2004.
4. Carter JT, Melcher ML, Carlson LL, et al. Thymoglobulin-associated Cd4+ T-cell depletion and infection risk in HIV-infected renal transplant recipients. Am J Transplant 2006; 6:753.
Will you accept this DBD donor?
-Yes, HIV organ policy equity act permits HIV +VE donor to register as donors. The recipients will have to be HIIV +VE, Donation to HIV neg recipients is still frowned upon and not yet acceptable.
-Other conditions to be met that would give us better outcomes;
Would you accept donor as live donor if recipient is also HIV positive? If yes what conditions should be met?
–Yes,I would accept.
-Conditions to be met;
If potential recipient has DSA(A36 with MFI 1550),but neg FCXM, what would be the mgt?
REF;
BTS guidelines 2017 – Kidney and pancreas transplantation in pts with HIV.
Will you accept this DBD donor?
· Transplantation using organs from HIV-infected individuals is restricted to organs from
deceased donors with:
a) HIV viral load <50 copies/mL and CD4 count >200/µL for at least 6 months prior to
brain injury
b) Information about the donor virus such as historical genotype patterns where
possible and current viral load
c) No history of virological failure or drug resistance
· Recipients are counselled and give informed consent both at the time of listing and at the time of transplantation
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
· Very few cases of HIV-to-HIV living donor transplantation are reported.
· The assessment of potential candidates for donor nephrectomy should include CD4+ cell count and HCV coinfection in addition to other conditions that preclude donation (e.g. DM, HTN, and preexisting kidney disease)
· HIV+ African American persons with high-risk apoprotein L1 (APOL1) genotypes are at risk for the development of HIVAN and FSGS.
· Post-nephrectomy, HIV+ donors should avoid nephrotoxic ART (such as tenofovir) in addition to agents such as nonsteroidal anti-inflammatory agents.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
· As MFI is not so high this patient does not need de-sensitization with is its risk of activation of the virus.
· ATG should be avoided, and Basiliximab is good choice for induction.
· Maintenance immunosuppressive regime may include Tacrolimus, Mycophenolate, and possible prednisone if the patient has high risk for rejection.
1) British Transplantation Society Guidelines. Kidney & Pancreas Transplantation in Patients with HIV
2)Organ transplantation in persons with HIV Rebecca N. Kumara and Valentina Stosor
Person with HIV can be accepted as donor ,specially after HOPE act
HIVAN has to be ruled out
for HIV positive recipient
if no opportunistic infection
CD4 more than 200/microL, viral copy less than 50 per ml – 6 months
no drug resistance
need to have viral genotype
should be in center regular with such transplants
yes we can accept kidneys from live donor
recipient criteria remains valid in this case as well
donor should have
no HIVAN
NO PROTEINURIA
NO HIV defining opportunistic infection
IN case of positive DSA AND negative FCXM-
Inducing agent like basiliximab is used and DSA need to be monitoring
ATG is associated with depletion of T cells and more chances of infection
Yes I will accept the donor but exclusion of HIVAN is must
Recommendations:
We recommend that transplantation using organs from HIV-infected individuals is restricted to organs from deceased donors with:
– HIV viral load <50 copies/mL and CD4 count >200/µL for at least 6 months prior to brain injury
– Information about the donor virus such as historical genotype patterns where possible and current viral load
– No history of virological failure or drug resistance (1D)
We recommend that recipients are counselled and give informed consent both at the time of listing and at the time of transplantation (1D)
We suggest that HIV+ organ use is restricted to those centres that have experience in transplanting HIV+ patients (Not graded)
We recommend that patients with HIV-infection are unsuitable to be living kidney donors (1D)
———————
Yes, we should to exclude donor HIVAN by kidney biopsy
the general consensus is that the recipient should have
The HOPE Act also allows people with HIV to be living donor to HIV infected recipient To become an HIV-positive living donor, you must:
—————————————-
induction therapy with basiliximab and monitoring of DSA
This donor can be accepted if both the deceased donor and recipient fulfill criteria for transplantation.
– Recipient is counseled regarding risk of getting HIV infection and information about the DD HIV condition.
-Criteria for DD:
..Protocol biopsy.
In the current scenario of positive HIV potential deceased donor to negative HIV recipient:
It is contraindicated.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met.
HIV-positive donor to HIV positive recipient can be accepted with preconditions in the recipient:
-Un undetectable viral load
-CD4 count >200
-It was traditionally considered an absolute contraindication for transplantation because of the concern that immunosuppression would accelerate HIV disease progression, resulting in increased mortality and a “waste” of organs. Currently in view of potent antiretroviral therapy (HAART) became widely available in 1996, the prognosis of patients with HIV infection has dramatically improved.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
-Regarding induction immunosuppression will proceed as a high risk of rejection.
Kidney transplant recipients with HIV have a high frequency of rejection. In a large, multicenter trial, one-and three-year rejection rates were 31 and 41 percent, respectively, compared with an expected one-year rejection rate of 12 percent.
There is a controversy regarding induction of IS some use basiliximab (an IL-2 receptor antibody) based upon data from two studies of kidney transplant recipients with HIV that demonstrated an increased risk of infection among those treated with rATG-Thymoglobulin . Other centers prefer to use rATG-Thymoglobulin given its superior efficacy in preventing acute rejection in recipients without HIV.
References:
Stock PG, Barin B, Murphy B, et al. Outcomes of kidney transplantation in HIV-infected recipients. N Engl J Med 2010; 363:2004.
Carter JT, Melcher ML, Carlson LL, et al. Thymoglobulin-associated Cd4+ T-cell depletion and infection risk in HIV-infected renal transplant recipients. Am J Transplant 2006; 6:753.
Will accept this donor to the positive HIV recipient if the viral HIV RNA is less than 50 copies/ml and CD4 count of more than 200.
Donors with HIV need to have normal kidneys with no proteinuria or elements of HIVAN.
The donor should be on HAART TREATMENT WITH no evidence of resistance.
The transplant will be to a positive HIV recipient with a CD4 count of more than 100
and should be stable for the last three months with undetectable HIV RNA , with no opportunistic infection.and no MLP
references
uptodate
1- We can accept only if
a- Donor:has
brain injury
b- Recipient: is HIV positive and :
stable during the previous 3 months (1B)
intestinal cryptosporidiosis, or lymphoma.
2- We can accept as a live donor:
after evaluating the donor for identification HIV-specific risk factors for development of ESRD such as low CD4+ cell count and HCV co-infection in addition to other conditions that generally exclude persons from donation (e.g. diabetes mellitus, hypertension, and preexisting kidney disease).
Very few cases of HIV-to-HIV living donor transplantation have been reported in the literature.
3- If patient has DSA (A36 with MFI 1550):
the DSA is not so high
You were offered kidneys from a 51-year-old male DBD (donor after brain stem death) donor who suffered from SAH (grade 5) complicating cerebral aneurysm. Her retrieval S Cr was 78 µmol/L. Virology was reported negative for both HBV and HCV, but HIV is positive.
Will you accept this DBD donor?
-Yes, HIV organ policy equity act permits HIV +VE donor to register as donors. The recipients will have to be HIIV +VE, Donation to HIV neg recipients is still frowned upon and not yet acceptable.
-Other conditions to be met that would give us better outcomes;
Would you accept donor as live donor if recipient is also HIV positive? If yes what conditions should be met?
–Yes,I would accept.
-Conditions to be met;
If potential recipient has DSA(A36 with MFI 1550),but neg FCXM, what would be the mgt?
REF;
4. You were offered kidneys from a 51-year-old male DBD (donor after brain stem death) donor who suffered from SAH (grade 5) complicating cerebral aneurysm. Her retrieval S Cr was 78 µmol/L. Virology was reported negative for both HBV and HCV, but HIV is positive.
Issues/ concerns
– 51yo male, DBD, suffered Grade 5 SAH complicating cerebral aneurysm
– retrieval sCr 78
– virology screen: HBV negative, HCV negative, HIV positive
Will you accept this DBD donor?
– yes, I would accept the DBD donor, as long as the potential recipient is HIV positive as well
– with the HOPE Act i.e., HIV Organ Policy Equity Act, HIV positive patients can now register as organ donors
– however, intentional transplantation of HIV positive organs to HIV negative recipients is still not an acceptable practice due to medical and ethical concerns
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met? (1)
– yes, I would accept him as a live donor – the HOPE Act permits HIV-positive living donation
– the recipient should be made aware of the potential risks and benefits of receiving HIV positive organ for transplant
– the potential donor must undergo a kidney biopsy prior to kidney donation
– there are a couple of concerns when dealing with HIV positive donors e.g.,
– some conditions to be met prior to transplantation, these include:
– transplant requirements for both the donor and the recipient include: –
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan? (1)
– multidisciplinary approach: HIV specialist, it is prudent to discuss the HAART regimen before transplantation due to the anticipated DDIs, also avoid nephrotoxic agents post-transplant
– history: current HAART regimen, OI history, any malignancies, compliance
– baseline investigations: CBC, UECs, LFTs, urinalysis, HbA1c, lipid profile, CD4, viral load, sputum gene xpert, HBV, HCV, HEV, chest radiograph, screen for OIs, malignancy screen
– immunosuppressive regimens should be individualized based on the immunologic risk, HAART regimen, liver function
– induction regimen:
– maintenance regimen:
– the best induction and maintenance immunosuppressive regimens are yet to be determined
– adequate trough levels should be maintained to avoid rejection
– drug-drug interactions (DDIs) do occur between HAART and the immunosuppressive agents
– DDIs can result in inconsistent immunosuppressive drug levels hence increasing the risk of rejection (in the case of sub-therapeutic drug levels) or risk of toxicity (in the case of supra-therapeutic drug levels)
– PIs are cytochrome P450 3A4 (CYP3A4) enzyme inhibitors whereas NNRTIs are enzyme inducers
– PIs are associated with poor outcomes (i.e., graft loss/ rejection and mortality) compared to non-PI based regimens
– non-boosted integrase strand transfer inhibitors (INSTI) are now a favourable option
– CD4 and HIV viral load should be monitored closely in the following case scenarios: – early post-transplant period, during graft rejection and when the immunosuppressive regimen is adjusted
– monitor CD4 and viral load at one month then every 3 months post-transplant
– offer the usual post-transplant prophylaxis against PJP, CMV, fungal infection, LTBI
References
1. Kumar RN, Stosor V. Organ transplantation in persons with HIV. AIDS (London, England). 2020 Jul 1;34(8):1107-16. PubMed PMID: 32167973. Epub 2020/03/14. eng.
British Transplantation Society Guidelines – Kidney & Pancreas Transplantation in Patients with HIV
DBD donor acceptance
Donor virology reveals negative for HBV and HCV but positive for HIV.
I would not accept this donor if the recipient is HIV negative/naive.
I would accept this donor if the following conditions are met :
Live donor, recipient, both HIV positive
Yes, I would accept live donor if the recipient is also HIV positive.
The conditions to be met are as follows :
Recipient DSA+, negative FCXM
Since the recipient is DSA positive A36 with MFI 1550, with negative FCXM, the following would be part of the management plan :
References
Will you accept this DBD donor?
Donor with negative HBV and HCV but positive HIV.
Yes I would accept this donor instead of wastage of the organs.
The recipient should however be counselled on the risk of infection and consent obtained.
Further conditions to be met should include:
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
If both donor and recipient are HIV positive, yes I would accept living donation.
Conditions to be met include:
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
FCXM negative with positive DSA the induction therapy should thus be with IL2RA- basiliximab.
Lymphocyte depleting agents should be avoided due to high risk of infections and malignancy.
Maintenance therapy should be triple therapy with CNI+mycophenolate+ steroids.
The antiretroviral with minimal drug interactions should be chosen prior to transplantation ideally integrate inhibitors and NRTI.
HIV virological monitoring should be done frequently, in the first month then every 2-3 months for the first year then every 3-6 months thereafter.
Recipient should be placed on lifelong PCP prophylaxis.
Other prophylaxis to be considered include CMV, toxoplasmosis, MAC,TB.
Frequent monitoring of the CNI trough levels.
References
Kidney & Pancreas Transplantation in Patients with HIV Second Edition
Compiled by a Working Party of The British Transplantation Society March 2015
[Minor Revision January 2017]
British Transplantation Society Guidelines
yes, I will utilize this kidney if an undetected viral load <50 copies last 6 months, CD4 count >100 (ideally >200), no hx of cART failure, no hx of progressive multifocal leukoencephalopathy, lymphoma, or intestinal cryptosporidiosis.
>Yes, with the same previous measures in the recipient in addition to the need for exclusion of HIVAN by hx, proteinuria assessment, & biopsy.
>regarding the donor, it is better to be of low immunological risk, so induction with basiliximab will be better with the same precaution regarding HIV viral load ,CD4 count , hx of opportunistic infection & hx of progressive multifocal leukoencephalopathy, lymphoma, or intestinal cryptosporidiosis.
> prophylaxis post-transplant for CMV, PCP, and toxoplasmosis, monitor closely for HIV PCR, CD4 count (every 2-3 months at 1st year), drug-drug interactions, proteinuria, and graft function.
>protocol biopsy may be considered.
induction with basiliximab
maintainace with steroid+tacrolimus+MMF
monitor DSA levels
Will you accept this DBD donor? yes, if the deceased donor and recipient full fill the criteria to proceed with transplantation, donnor HIV viral load< 50 copies/ml and CD count >200/ul for at least 6 months prior to brain injury.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
yes if the receipt meet criteria of low viral load and high CD count with no opportunistic infections or malignancies.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Will you accept this DBD donor?
Yes I will accept if fulfill criteria :
1.Patients demonstrate overall concordance with recommended treatment, and with cART therapy in particular .
2. CD4+ T cell levels are a minimum of 100 cells/µL and ideally >200 cells/µL and have been stable during the last 3 months .
3. HIV RNA has been undetectable during the last 3 months .
4.No opportunistic infections have occurred during the last 6 months .
5. No history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma .
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Many centres of transplantations take a postive HIV donor as contraindication .but I will accept ,after doing donor genotypic testing to confirm lack of resistance , the recipient should be counselled about the risk of transmission of viral resistance. Preimplantation biopsies may be considered to detect donor disease(HIVAN) .
The risk of recipient super-infection, recombinant virus or virus from a different clade, loss of virological control or transmission of viral resistance.
Transplantation may offer the outcomes at 3 to 5 years.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
low titer DSA, but negative flow cross match, this is moderate transplant.
However since the recipient is HIV positive so risk of infections is high, so avoiding ATG will be wise decision .
basiliximab instead with standard triple immunosuppression.
Monitoring the DSA .
References
1. Kumar MS, Sierka DR, Damask AM, et al. Safety and success of kidney transplantation and concomitant immunosuppression in HIV-positive patients. Kidney Int 2005; 67: 1622-9.
2. Swanson SJ, Kirk AD, Ko CW, et al. Impact of HIV seropositivity on graft and patient survival after cadaveric renal transplantation in the United States in the pre highly active antiretroviral therapy (HAART) era: an historical cohort analysis of the United States Renal Data System. Transpl Infect Dis 2002; 4: 144-7.
3. Muller E, Kahn D, Mendelson M. Renal transplantation between HIV-positive donors and recipients. N Engl J Med 2010; 362: 2336-7.
4. Hilton R. Human immunodeficiency virus infection and kidney disease. J R Coll Physicians Edinb 2013; 43: 236-9.
5. 2-BTS guidelines 2015
Will you accept this DBD donor?
No, I will not accept this donor untill, I have HIV viral load status as per the inclusion criteria and HIVAN is ruled out.
Personally I feel that there cannot be any emergency for a CKD patient on maintainance dialysis that he has to be given an infected organ when he himself is HIV negative and that to from DBD donor where many other factor responsible for decreased graft survival come in to play as compared to live donor.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met.
Yes, I will accept this donor if following criteria are met.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
No, I will not accept this kidney. There is currently insufficient data available to confidently comment that DSA positive FCXM negative recipient has favourable long term outcome.
The literature available states that it has acceptable outcome in short term. But when there is already an added risk factor of HIV positivity, I will refrain from taking bthis risk.
REF:
Will you accept this DBD donor?
HIV-infected organs should only be transplanted from deceased donors with no HIVAN, if the recipient is also HIV positive and the following criteria are met by the recipent:
Has undetectable HIV RNA for last 6 months, CD4 count ideally >200/μL for more than 3 months, absence of opportunistic infection in last 6 months, and no history of lymphoma, cryptosporidiosis, and progressive multifocal leukoencephalopathy.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes, if the recipient is also HIV positive transplantation can be done provided the following conditions are met:
Donor Criteria:
Recipient Criteria:
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
References:
British Transplantation Society. Kidney and Pancreas Transplantation in patients with HIV, 2nd ed.; British Transplantation Society: Macclesfield, UK, 2017; Available online: https://bts.org.uk/wp-content/uploads/2017/01/02_BTS_Kidney_Pancreas_HIV.pdf
Excellent
Yes, I will accept this deceased HIV known donor patient .This can be donated to HIV positive recipient. Provided that there is proper patient centered counselling and consent.
Yes this can be approved provided that certain conditions ought to be met for both the donor and the recipient.
Regarding the recipient; preferred to be fit, adherent to HIV medications (c ART therapy), their CD4 count is acceptable (between 100 to 200 cells /ul at least), with stable clinical condition for the last 3 months, with undetectable HIV RNA for at least 6 months, history must be free from any opportunistic infections the previous 6 months, no history suggestive of Progressive multifocal leukoencephalopathy (PML), having proper vaccination protocol.
Regarding the living donor, it is preferred to be better matched especially DR loci, with proper counselling with the expected risk for development of CKD or HIVAN. Besides the previously explained recipient conditions regarding clinical and laboratory assessment.
The donor should be aware of the necessary follow up post donation for HIV status, renal profile with special attention to development of proteinuria or any associated comorbid conditions.
Transplantation can be performed as long as FCXM is negative, however precautions are to be taken in consideration with immunosuppression induction (basiliximab is fine for induction) along with triple immunosuppressive regimen preferred to be tacrolimus based besides steroids and MMF. Another important alert to the drug level with other c ART therapy and proper dosing to avoid expected drug interactions. Prophylaxis against CMV, PCP, and other opportunistic infections is to be extended preferably according to patient status. Meticulous follow up for DSA levels, protocol biopsies are to be performed based on the centre’s protocol. Follow up HIV RNA levels and CD4 count on frequent basis is crucial particularly in the first year.
Reference
British transplantation society guidelines
https://bts.org.uk/wp-content/uploads/2016/09/05_BTS_Kidney_HIV-1.
Yes, a donor with HIV can be accepted to expand the donor with certain criteria to minimize the risk to recipient. He can donate a kidney to someone who is HIV positive. On November 21, 2013, the HOPE Act (HIV Organ Policy Equity Act) was signed into law. This law allows people with HIV to register as organ donors. People with HIV on the transplant wait list at approved centers can choose to accept these organs. (In other words, organs from HIV-positive donors are only offered to HIV-positive transplant candidates.) The transplant center will look at the deceased donor’s CD4 counts and HIV viral loads, but there is no absolute threshold for either. Some centers. BTS guidelines recommend: Transplantation using organs from HIV-infected individuals is restricted to organs from deceased donors with:
a) HIV viral load <50 copies/mL and CD4 count >200/μL for at least 6 months prior to
brain injury.
b) Information about the donor virus such as historical genotype patterns where
possible and current viral load.
c) No history of virological failure or drug resistance.
To be considered a living donor, he should meet certain criteria:
1-CD4 count>500/microL for last 6 months.
2-HIV RNA <50 copies/ml.
3-No invasive opportunistic complications of HIV. They should undergo a pre-implantation biopsy. Donor should undergo all routine pre donation workup.
Having low titer DSA, but with negative flow crossmatch, puts him at moderate transplant. However since the recipient is HIV positive so risk of infections is high, so avoiding ATG will be wise decision and give basiliximab instead with standard triple immunosuppression. Monitoring the DSA is important in such case.
References:
1-Transl An Challenges of kidney transplantation in HIV positive recipients
Mahmoud Alameddine1, Joshua S. Jue2, Ian Zheng1, Gaetano Ciancio
2-BTS guidelines 2015
Thanks
Will you exclude HIVAN in an HIV-POSITIVE living donor?
Will you accept this DBD donor?
The current donor is negative for HBV and HCV but he is HIV positive.
This donor can be accepted for HIV positive recipient only as long as donor’s kidney biopsy doesn’t show HIV-AN.
This donor should have the following criteria before donation:
1- HIV viral load below 50 copies/ml for at least 6 months before head njury.
2- CD4 above 200/ul for at least 6 months before head injury.
3- No history of virological failure or drug resistance.
4- No evidence of HIV-AN by kidney biopsy.
5- No evidence of proteinuria.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
According to BTS guidelines 2017; patients with HIV infection are deemed unsuitable for living kidney donation.
I would accept this HIV positive donor as a living donor to HIV positive recipient if the following criteria are fulfilled as per HIV Organ Policy Equity Act 2013(HOPE 2013):
1- Undetectable viral load (less than 50 copies/ml) for the last 6 months.
2- CD4 above 200 for the last 6 months.
3- No history of invasive infection like PJP, fungal meningitis.
4- No evidence of HIV-AN by kidney biopsy.
5- No evidence of proteinuria.
6- Fulfilling all requirement by the transplant center.
On the other hand, the recipient should fulfill the following criteria as well:
1- Expected life survival above 5 years.
2- Compliant on HAART.
3- CD4 count above 100 cells/ul and being stable during the last 3 months.
4- Undetectable HIV viral load (less than 50 copies/ml for the last 6 months.
5- No history of opportunistic infection for the last 6 months.
6- No history of PML, Cryptosporidiosis or lymphoma.
· Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Presence of DSA with negative flowcytometry cross-match makes the donation offer acceptable especially DSA is against A36 with MFI 1550 (not a high titer) with low risk of hyper-acute rejection. No need for desensitization before renal transplantation.
Pre-transplant vaccination as per guidelines in HIV patients.
Induction regimen: Basiliximab (IL-2 R anatagonist), avoid ATG and Almetuzumab in HIV positive recipients.
Maintenance: Triple IS (Tacrolimus+steroids+MMF).
Post-transplant prophylaxis against PJP and CMV as per guidelines.
Monitor drug levels, kidney function test., and DSA level.
References:
1- National Kidney foundation. HIV and Kidney Transplantation/Donation.
2- BTS kidney and pancreas transplantation in patients with HIV-2017.
3- Kidney & Pancreas Transplantation in Patients with HIV Compiled by a Working Party of The British Transplantation Society March 2015.
Excellent, well done
Yes I will accept if the recipient is HIV positive or recipient negative but should be written consent and counselling regarding risk of transmission.
Yes if both are positive but should met criteria of HIV viral load is less than 50 copies and T CD 4 more than 200 and no evidence of opportunities infection and treatment by HAAT
Thanks
Will you exclude HIVAN in an HIV-POSITIVE living donor?
⭐ yes, I will accept this donor (but only for HIV postive recipient ) with the following precautions:
_Donor has negative HIV PCR less than 50 copies /ml and CD4 cell count > 200 cells /ml in preceding 6 months prior to death, in addition to absent history of ART resistance or non adherence or history of active opportunistic infection.
_exclusion of HIVAN in the donor by urine analysis (exclude hematuria and protinuria ), also by biopsy
_The recipient must be HIV postive with control of infection, adherence to ART and CD4 cell count > 200, HIV PCR negative, bo active opportunistic infection or malignancy .
⭐ ⭐ living donation from HIV donor is still just in few case series .
_If it is used , only for HIV postive recipient.
_Obtain consent from both donor and recipient .
_only after counseling the donor about risk of donation and avoid nephrotoxic ART as tenofovir after nephrectomy.
_Recipient should have close follow up of graft function.
_close follow up of HIV control (HIV PCR, cd4 cell count).
_cloae follow up of trough level (avoid protease inhibitors nad better use of integrase inhibitors ) to minimized drug-drug interactions with CNI
👉 👉 As long as FCXM is negative, proceed with Tx after prerequisites of HIV recipient ….induction with basiliximab and use of TAC based triple therapy to prevent AR (as DSA is postive ).
_ close follow up of DSA titre and protocol biopsy to detect subclinical rejection.
_treatment of ABMR is indicated based on biopsy (not only presence of DSA).
_treatment as HIV naive (PEX, IVIG and rituximab).
_close monitoring of trough level of CNI (avoid protease inhibitors ART and use of integrase inhibitors)
_ use of prophylaxis against PJP and CMV as HIV naive.
Thanks
Will you exclude HIVAN in an HIV-POSITIVE living donor?
👉👉sure, exclusion of HIVAN in the living donor is more crucial than in deceased one for the sake of both the donor and recipient.
_HIVAN in the donor carries a risk of his progression to ESKD and precludes donation. In addition, it indicates either late initiation or non adherence to ART so all against accepting donation.
_For the recipient, it has risk of allograft failure and poor patient and graft outcome
1-In the last decades, the utilization of HIV-positive patients has grown. In 2003 started with D-/R+ followed by D+/R+ and lastly D+/R-. We need to discuss this with the recipients and take their consent and then we can accept if eligibility criteria are available. anti-HIV positive patients can donate if viral load is low az <50 copies with CD4>200 and clinical stability of at least 6 months.
2-HIV-positive to positive donation can be done but we need to fulfil the criteria regarding the recipient: compliance with cART therapy, CD4+ T cell count >100 (preferably more than 200) with stable clinical picture free of opportunistic infections at least for 6 months and no history of HIV associated nephropathy, PML etc.
3- As low-risk, we can use non-depleting agents lide Basiliximab, followed by triple IS maintenance. (TAC/MMF/steroid)
————-
**Botha J, Fabian J, Etheredge H, Conradie F, Tiemessen CT. HIV and Solid Organ Transplantation: Where Are we Now. Curr HIV/AIDS Rep. 2019 Oct;16(5):404-413. doi: 10.1007/s11904-019-00460-7. PMID: 31482298; PMCID: PMC6813753.
** BTS guidelines
Thanks
Will you exclude HIVAN in an HIV-POSITIVE living donor?
Will you accept this DBD donor?
If both the donor and recipient are HIV positive, I will accept them as potential candidates for kidney transplantation.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Before accepting donor, any sign of nephropathy should be excluded.
Recipient should have
· HIV PCR viral count less than 50 and T-Cell CD4 count more than 200 for the past 6months
· Life expectancy is more than 5 years
· Patient compliant on HAART for the past 6 months
· No opportunistic infection for the past 6 months
· Counseled about the risk of both high rejection rate and reactivation of viral replications
· Malignancy screening
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Induction with Basiliximab because the risk of acute and hyperacute rejection is low and continue with the maintenance triple therapy with follow up of graft function . continue on antiretroviral therapy with monitoring of drug interaction.
Reference:
British Transplantation Society Guidelines
Thanks
Will you exclude HIVAN in an HIV-POSITIVE living donor?
Yes, we can proceed with the donation
According to BTS guideline
We recommend
a) They are concordant with treatment, particularly cART therapy (1D)
b) Their CD4+ T cell count is > 100 cells/microL (ideally > 200 cells/microL) and has been stable the previous 3 months (1B)
c) HIV RNA has been undetectable during the previous 6 months (1B)
d) No opportunistic infections have occurred during the previous 6 months (1B)
e) They have no history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma (1B)
We suggest
Use of HIV-infection donors for HIV-infected recipients
We recommend
a) HIV viral load <50 copies and CD4 count >200 for at least 6 months prior to brain injury.
b) Information about the donor virus such as historical genotype patterns where possible and current viral load.
c) No history of virological failure or drug resistance (1D)
We suggest that
As a liver donor, we can accept and proceed with the consideration
As the outcome of liver transplantation with HIV+ varies according to the reason for transplantation
a) Recipient should be disclosed that he will receive a graft from an HIV+ donor
b) The transplantation is confined to HIV D+/HIV R+
c) Liver disease can occur due to HIV infection as a complication of ART.
d) HIV-HBV co-infection, the graft, and patient survivals range from 85 to 100% after 3-5 years of follow-up, due to the frequency of breakthrough HBV viremia, lifelong prophylaxis is recommended.
e) HIV-HCV co-infection, before DAA the outcome is significantly lower in graft and patients survival, compared to HCV-mono-infection, with estimated 1,3, and 5-years graft survival 52 to 86%, 45 to 60%, and 31 to 45% respectively, while HCV-mono-infection ranged from 57 to 88, 50 to 62, and 358% respectively.
If the potential recipient has DSA (A36 with MFI 1550), but negative FCXM
Refferences
Amico P, Honger G, Mayr M, Steiger J, Hopfer H, Schaub S. Clinical relevance of pretransplant donor-specific HLA antibodies detected by single-antigen flow-beads. Transplantation. (2009) 87:1681–8. doi: 10.1097/TP.0b013e3181a5e034
Lefaucheur C, Loupy A, Hill GS, Andrade J, Nochy D, Antoine C, et al. Preexisting donor-specific HLA antibodies predict outcome in kidney transplantation. J Am Soc Nephrol. (2010) 21:1398–406. doi: 10.1681/ASN.2009101065
Health Protection Agency. HIV in the United Kingdom: 2013 Report. http://www.hpa.org.uk Accessed June 2014. 2. Mocroft A, Ledergerber B, Katlama C, et al. Decline in the AIDS and death rates in the EuroSIDA study: an observational study. Lancet 2003; 362: 22-9. Williams I, Churchill D, Anderson J, et al. British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2012. HIV Med 2012; 13 Suppl 2: 1-85. 4. May MT, Gompels M, Delpech V
Thanks
Will you exclude HIVAN in an HIV-POSITIVE living donor?
Will you accept this DBD donor?
I will accept this potential donor, only for HIV positive recipient.
If the recipient is HIV negative, this potential donor will not be suitable and I would not proceed forward in the transplant process.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes, I will accept this donation and proceed in the transplant process with HIV serostatus D+/R+. HIV per se is not a contraindication for kidney transplantation(1).
Transplantation using organs from HIV-infected individuals is restricted to organs from deceased donors if the following conditions are met(1):
a) HIV viral load <50 copies/mL and CD4 count >200/μL for at least 6 months prior to brain injury.
b) Information about the donor virus such as historical genotype patterns where possible and current viral load.
c) No history of virological failure or drug resistance.
The transplant recipient should meet the following criteria:
a) HIV RNA has been undetectable during the previous 6 months.
b) No opportunistic infections have occurred during the previous 6 months.
c) They have no history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
· A36 is rare HLA-A allele group. A36 is more common in Africa (North and East) and Central Asia.
· I will proceed in the transplant process after counselling the transplant candidates and explaining to them the risk of rejection and sequelae of HIV infection in the post-transplant period.
· I will consider induction therapy with Basiliximab (IL-2RA).
· For maintenance IS I will consider the triple of TAC, MMF and prednisolone.
References
1. Kidney & Pancreas Transplantation in Patients with HIV Second Edition Compiled by a Working Party of The British Transplantation Society March 2015 [Minor Revision January 2017]
Thanks
Will you exclude HIVAN in an HIV-POSITIVE living donor?
=Will you accept this DBD donor?
Yes, I will.
The DBD donor should have the following criteria.
1-HIV viral load of <50 copies/ml and CD4 count of >200/microL for minimum 6 months.
2-No history of invasive opportunistic infections, virological failure, or drug resistance.
3-To rule out HIV associated nephropathy (HIVAN) .
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
No, I will not accept.
Transplantation using organs from HIV-infected individuals is restricted to organs from deceased donors with special criteria as mentioned above, patients with HIV-infection are unsuitable to be living kidney donors and no clear consensus guidelines about this issues.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
We can proceede with use of induction therapy (Basiliximab) and maintenance immunosuppression in form of Tacrolimus, Mycophenolate mofetil and steroids.
We should be cautious about antiretroviral with nephrotoxic potential and with significant drug interaction with tacrolimus .
Prophylaxis for pneumocystis jirovecii should be given, CMV prophylaxis for minimum 3 months for D+/R- pair and Toxoplasma prophylaxis in setting of donor seropositive for Toxoplasma should be given.
Monitoring of HIV RNA and CD4 count at 1 month, and then every 2-3 months till 12 months, and then 3-6 monthly.
Post-transplant monitoring of DSA and a protocol biopsy at 3 months should be done .
References:
1. British Transplantation Society. Kidney and Pancreas Transplantation in patients with HIV.
2. Blumberg EA, Rogers CC; American Society of Transplantation Infectious Diseases Community of Practice. Solid organ transplantation in the HIV-infected patient: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13499. doi: 10.1111/ctr.13499. Epub 2019 Apr 21. PMID: 30773688.
3. Sawinski D. Kidney Transplantation in Patients with HIV. Kidney360. 2020 May 6;1(7):705-711. doi: 10.34067/KID.0002112020. PMID: 35372947; PMCID: PMC8815555.
Did you mention in the first question the R should be also +ve for HIV?!
Your second choice is clear that an HIV living donor is not a suitable donor strictly speaking!
Thanks professor Dawlat.
Yes it supposed to be HIV positive with standard criteria for transplantation as mentioned in BTS
Will you accept this DBD donor?
Yes, I will accept this deceased donor (for HIV recipient)with:
1. HIV viral load <50 copies/mL and CD4 count >200/µL for at least 6 months prior to brain injury
2. Information about the donor virus such as historical genotype patterns where possible and current viral load
3. No history of virological failure or drug resistance
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes, I will accept HIV1 to HIV+
HIV+ transplant recipient criteria:
1. They are concordant with treatment, particularly cART therapy
2. Their CD4+ T cell counts are >100 cells/µL (ideally > 200 cells/ µL) and have been stable during the previous 3 months (1B)
3. HIV RNA has been undetectable during the previous 6 months
4. No opportunistic infections have occurred during the previous 6 months
5. They have no history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
o Induction therapy at the time of transplantation with IL-2RA (basiliximab)
o Maintenance immunosuppressions started at the time of kidney transplantation, include steroids, a CNI and an anti-proliferative agent (1C)
o Explain the high risk of acute rejection (treated in the same way as HIV-negative kidney transplant recipients)
References
1. Kidney & Pancreas Transplantation in Patients with HIV, BTS guidelines, March 2015.
2. Sawinski, Deirdre. Kidney Transplantation in Patients with HIV. Kidney360 1(7):p 705-711, July 2020. | DOI: 10.34067/KID.0002112020
Well done
The index donor is a DBD (donor after brainstem death) donor with good renal function and negative HBV and HCV, but a positive HIV report.
Yes, this donor can be accepted, but only for HIV positive recipient.
The DBD donor should also fulfil certain criteria before accepting such a donor, which include HIV viral load of <50 copies/ml and CD4 count of >200/microL for minimum 6 moths prior to the brain injury and no history of invasive opportunistic infections, virological failure, or drug resistance. The urine analysis of the donor should not be having anu proteinuria/ hematuria, and if needed, a pre-implantation kidney biopsy to rule out HIV associated nephropathy (HIVAN) should be performed (1).
The prospective recipient should be counselled regarding the risk of transmission of opportunistic infections, other HIV strains, and viral resistance prior to proceeding with transplant (1,2).
The prospective recipient should also fulfil certain criteria which include being concordant with cART treatment, having undetectable HIV RNA for last 6 months, CD4 count >100/microL (ideally >200/microL) for more than 3 months, absence of opportunistic infection in last 6 months, and no history of lymphoma, cryptosporidiosis, and progressive multifocal leukoencephalopathy.
The transplant should take place in a center with experience in managing such transplants.
According to the British Transplantation Society guidelines, HIV-infection makes a person unsuitable as a living kidney donor (1).
Nevertheless, a prospective donor with HIV-positive status can be accepted as a living donor for a HIV-positive recipient if certain criteria are fulfilled as per the HOPE Act.
Donor evaluation: A living donor should undergo all the routine pre-donation work-up as per protocol for all donors. In addition, the donor should also fulfil criteria including CD4 count>500/microL for last 6 months, and HIV RNA <50 copies/ml and no invasive opportunistic complications of HIV (3). They should undergo a pre-implantation biopsy (4). The donor should not have APOL1 variant, as it is associated with high risk of subsequent renal disease to both the donor and recipient.
Recipient evaluation: The recipient, in addition to the transplant work-up protocol for a routine HIV-negative transplant candidate, must fulfill certain other criteria which include being concordant with cART treatment, having undetectable HIV RNA for last 6 months, CD4 count >100/microL (ideally >200/microL) for more than 3 months, absence of opportunistic infection in last 6 months, and no history of lymphoma, cryptosporidiosis, and progressive multifocal leukoencephalopathy. Pre-transplant assessment for syphilis, HSV (Herpes simplex virus), EBV (Epstein Barr virus), CMV (cytomegalovirus), VZV (varicella zoster virus), HTLV (human T-cell leukemia virus), Toxoplasma gondii, active tuberculosis, latent Tuberculosis, HBV, HCV, cervial and/or anal neoplasia evaluation should be done (1).
If the index recipient has DSA (A36 with MFI 1550), but FCXM is negative, the transplant can be proceeded with use of induction therapy (Basiliximab) and maintenance immunosuppression in form of Tacrolimus, mycophenolate mofetil and steroids. Antiretrovirals with nephrotoxic potential and with significant drug interaction with tacrolimus should be changed prior to transplant.
Post-transplant, lifelong prophylaxis for pneumocystis jirovecii should be given. CMV prophylaxis for minimum 3 months for D+/R- pair and Toxoplasma prophylaxis in setting of donor seropositivity for Toxoplasma should be given.
HIV RNA and CD4 count should be monitored at 1 month, and then every 2-3 months till 12 months, and then 3-6 monthly.
Post-transplant monitoring of DSA and a protocol biopsy at 3 months should be done (5). In presence of antibody mediated rejection (AMR) in biopsy, treatment should be done. If the DSA is increasing, then the immunosuppression should not be reduced. If the DSA is not increasing, and there is no AMR, then follow-up DSA level should be tested at 12 months and whenever there is any significant change in immunosuppression, graft dysfunction, or suspected non-adherence (5).
References:
Avery good answer.
good you acknowledged :
Donor kidney profile follow up.
DSAs follow up.
People with HIV were allowed to be living donors but they should meet all requirements of the transplant center with CD4 count over 500
and undetectable viral load plus negative history of invasive infections ,kidney biopsy is mandatory in those patients to exclude HIVAN .
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Reference :
1. AIDS. 2020 Jul 1;34(8):1107-1116. doi: 10.1097/QAD.0000000000002518.
2. Nephrol Nurs J. 2017 May-Jun;44(3):230-249
3. British Transplantation Society Guidelines
Very good you are considering the donor kidney function.
1. HIV viral load <50 copies/mL and CD4 count >200/μL for at least 6 months prior to brain injury
2. Information about the donor virus such as historical genotype patterns where possible and current viral load
3. No history of virological failure or drug resistance
4. no evidence of active opportunistic infections
5. Absence of chronic wasng or severe malnutrion
6. informed consent should be given
7. Pre- implantation biopsies may be considered to detect donor disease as HIV at risk of CKD
·
as a living donor HIV patients
are not stable for organ donation
IF recipient has DSA (A36 with MFI 1550), but negative FCXM.
I would prefer Basiliximab for induction
In the U.S. NIH observational trial, persons who received ATG as opposed to basiliximab, experienced significant, prolonged lymphocyte depletion, more frequent and severe infections, and increased risk for allograft loss . Other investigators, through analysis of registry data, reported lower rejection and infection rates with ATG .Based on this, choice of induction agent should be individualized
Well done for your analysis, but to make matters more clear consider the option of :
Would you offer this HIV +ve to an HIV -ve R?
No i will not
As per British society of organ transplanation kidney transplant is the best RRT for HIV ESRD patients associated with better morbidity and mortality.
As long as both donor and recipient are HIV positive so i will accept them as potential candidates for kidney transplantation with special precautions as
Kidney donor should be healthy individual with low risk of developing ESRD.HIV are in risk of developing HIVAN so,i will not accept him as potential donor but if he/she insist to donate after proper counseling about risk and benefits i will proceed if urine analysis showed no proteinuria and kidney biopsy was normal.
regarding recipient, he/she
HIV patient is high risk patient with high risk of rejection.some centers routinely do protocol biopsy for this specific group of patients.
DSA against class I even with low MFI consider more risk for already risky patient
I would prefer to wait for better offer unless patient in urgent need to organ due to failed vascular access or highly sensitized patient on the waiting list for long period and he was counseled regarding risk of rejection which will need aggressive treatment with risk of viral reactivation and short term graft survival and still accepting to proceed.
as long as FCXM is negative no need for desensitization and i will go with basiliximab non depleting induction with maintenance triple immunosuppresion including TAC,MMF and steroids.
References
British Transplantation Society Guidelines. Kidney & Pancreas Transplantation in Patients with HIV March 2015 [Minor Revision January 2017]
Thankyou for the clear decision making.Well done.
Will you accept this DBD donor?
-Yes, Transplant candidates need precise immuno-virological and antiretroviral status evaluation as CD4 cell count, HIV RNA level, present and previous antiretroviral treatments, HLA-B5701 status and HIV resistance profile.
HIV-infected deceased donors to be suitable for transplantation has to have
-HIV viral load <50 copies/mL and CD4 count >200/µL for at least 6 months before brain injury
-Information about the donor virus such as historical genotype and viral load
-No history of drug resistance
· Recipients are counselled and give informed consent both at the time of listing and at the time of transplantation ·
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes ,Cases having HIV RNA levels <200 copies/mL can be suitable for transplantation if all other issues are in acceptable range.
• Possible donors for HIV infected cases have to be informed of medical, surgical, and psychosocial factors that can affect the recipient’s morbidity and mortality risk but disclosing the recipient’s HIV status is not a must
• guidelines on the ethics of living donor transplantation need to be followed for all transplantation including those with HIV disease and the same standard of consent
• Transplant teams must guarantee the adequacy of donor consent and the transparency of procedures in advance
· the recipient is encouraged to inform their diagnosis of HIV to their donors
· the donor must be asked if there is any medical disease that can let them reject donation without saying it is HIV also donors have to be informed that there is a medical condition the recipient has but is unrevealed
· living donors need to be acknowledged that they are aware that confidential data concerning the recipient won’t be told to them
It is suggested that HIV+ organ transplant to be carried out only in centres that have experience in transplanting HIV+ cases
Patients with opportunistic infections and neoplasms without effective medical therapy are excluded as progressive multifocal leukoencephalopathy (PML), chronic intestinal cryptosporidiosis. Visceral and systemic Kaposi’s sarcoma are no longer contraindicated, as long as the disease is successfully eradicated with the use rapamycin
All possible recipients are routinely screened for TB , syphilis and hepatitis C pre-transplant. As well as strongyloidiasis screening in epidemic area
Treatment/screening for co-infection for HBV/HCV are needed before transplantation.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Induction of therapy can be IL2 receptor antagonist but TB screening is needed before therapy
Maintenance Tac MMF ,prednisolone
Prophylaxis against fungal infections, Pneumocystis pneumonia (PCP), and Cytomegalovirus infection (CMV)
Pneumococcal Polysaccharide Vaccine (PPSV) and Pneumococcal Conjugate Vaccine (PCV) should be given pretransplant
The interaction between protease and non-nucleoside reverse transcriptase inhibitors with the calcineurin and mTOR inhibitors, is challenging rendering treatment difficult , with close drug monitoring
Reference
-Kidney & Pancreas Transplantation in Patients with HIV .Second edition ,Compiled by a Working Party of The British Transplantation Society March 2015 [Minor Revision January 2017]
-Muller E, Botha FCJ, Barday ZA, Manning K, Chin-Hong P, Stock P. Kidney Transplantation in HIV-positive Patients: Current Practice and Management Strategies. Transplantation. 2021;105(7):1492-1501.
Thankyou the viral load should be less than 50 copies.
This is a LD so he should also get a fair attention and follow up for virus status and proteinuria.
Will you accept this DBD donor?
I will accept this donor for HIV positive recipients only. Certain criteria have to be met for donor:
· HIV Viral load < 50 copies /ml
· CD 4 counts > 200 at least 6 months prior to brain injury
· Where possible info on current viral load and genomic pattern
· Absence of drug resistance
· HIVAN is excluded
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
YES
I will accept him
Potential HIV positive donors should be informed about medical , surgical and psychological implications and recipient morbidity.
Information pertaining to recipient need not to be disclosed.
Pre requisites for Kidney donation:
HIV Viral load < 50 copies /ml
CD 4 counts > 200 at least 6 months prior to brain injury
Where possible info on current viral load and genomic pattern
Absence of drug resistance
HIVAN is excluded
Pre requisites for recipients
Undetectable viral load for 6 months
Compliance with cART
Cd 4 Counts > 200 cells/ml for > 3 months
No opportunistic infection in last 6 months
No evidence of HIV related malignancy
Ability to have regular follow ups
Recipients have to be counselled in detail and transplant centres should preferably have experience in HIV positive transplantation.
History of Vaccination- MMR, Influenza, VZV, Pneumococcal, DTP, HPV, Heepatitis A , B
Have to take history of infections like EBV, Tuberculosis, Mycobacterium Avium, Toxoplasma Gondii, , CMV etc
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
I will proceed with Basiliximab induction and triple immune suppression as TAC, MMF and Prednisolone.
All pre requisites for donor and recipient have to be met
CD4 counts and HIV RNA quantitative monitoring
Botha J, Fabian J, Etheredge H, Conradie F, Tiemessen CT. HIV and Solid Organ Transplantation: Where Are we Now. Curr HIV/AIDS Rep. 2019 Oct;16(5):404-413.
Muller E, Barday Z, Kahn D. HIV-positive-to-HIV-positive kidney transplantation. N Engl J Med. 2015 May 21;372(21):2070-1. doi: 10.1056/NEJMc1503288. PMID: 25992753; PMCID: PMC4633687.
Would you consider follow up of the donor for proteinuria ( HIVAN) apart from his HIV status?!
A 51-year-old male DBD donor donated kidneys from SAH-complicating cerebral aneurysm with 78 µmol/L retrieval, negative for HBV, HCV, but HIV is positive.
Will you accept this DBD donor?
Yes, I will accept this donor to HIV infected recipient after fulfilling the following criteria:
After counseling the recipient patient.
Viral load > or = 200/ml for at least 6 months before the brain injury.
Excluding HIVAN by absence of proteinuria and a kidney biopsy.
With continuation of HAART after transplant and the recipient fit for
intervention.
Would you accept this donor as a live donor if the recipient is also HIV positive?
HIV Organ Policy Equity Act- 2013)
The viral load is undetectable or less than 50 copies/ml and CD4 > 200 for the last 6 months.
No evidence of HIV associated nephropathy by performing a kidney biopsy and checking for proteinuria.
Has no evidence of invasive infection, PCP, or active fungal meningitis.
Meet all the requirement of the transplant center.
Transplants may be the only option to prolong life for HIV/AIDS patients with end-stage organ disease.
Patients with ESRD should have a life expectancy of at least five years before transplantation.
HIV-associated nephropathy is the most common cause of ESRD in HIV-infected patients, especially in black patients.
HIV-positive patients on dialysis have improved survival and morbidity, but the complexities of antiretroviral therapy dosing have prompted consideration of renal transplantation.
HIV infection is no longer an absolute contraindication for renal and liver transplants to stable HIV-positive patients.
Graft and patient survival are comparable to non-HIV infected recipients of both cadaveric and live-related donor kidney transplants, but there are still issues to address.
BTS Guidelines:
HIV per se is not a contraindication for kidney transplantation. (1B)
Recipients are counselled and give informed consent both at the time of listing and at the time of transplantation. (1D)
HIV+ organ use is restricted to those centres that have experience in transplanting HIV+ patients. (Not graded)
Transplantation using organs from HIV-infected individuals is restricted to organs from deceased donors with:
a) HIV viral load < 50 copies/mL and CD4 count > 200/µL for at least 6 months prior to brain injury,
b) Information about the donor virus such as historical genotype patterns where possible and current viral load,
c) No history of virological failure or drug resistance. (1D)
If yes, what are the conditions that should be met?
The Recipient Should Fulfill the Following Criteria:
Fit with life expectancy of > Five years.
Concordant with HAART therapy (1D)
CD4+ T cell counts are >100 cells/μL (ideally > 200 cells/ μL) and have been stable during the previous 3 months (1B).
Fully HIV RNA load and CD4 > 100 (2C).
HIV RNA undetected or less than 50 copies/ml for the last 6 months (1B).
No history of opportunistic infection for the last 6 months (1B).
No history of PML (Progressive multifocal leukoencephalopathy), chronic
intestinal cryptosporidiosis, or lymphoma (1B).
All potential kidney transplant recipients are screened for HIV infection (1D)
HIV per se is not a contraindication for kidney transplantation (1B)
HIV-positive patients are wait-listed only if:
They are concordant with treatment, particularly cART therapy (1D)
Their CD4+ T cell counts are >100 cells/μL (ideally > 200 cells/ μL) and have been stable during the previous 3 months (1B)
HIV RNA has been undetectable during the previous 6 months (1B)
No opportunistic infections have occurred during the previous 6 months (1B)
They have no history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma.
Relative contraindications to kidney transplantation:
Positive flow cytometric crossmatch (FCXM) (1D)
ABOi Blood-type incompatibility (2D)
Treated malignancy, including extracutaneous Kaposi sarcoma (2C)
Severe and/or uncontrolled medical problems that are unlikely to improve after kidney transplantation and will shorten the patient’s life expectancy (2D)
Chronic liver disease (2D)
Marked obesity (BMI >35 kg/m 2) (2D)
HTLV infection (1D
The following should be considered absolute contraindications:
Uncontrolled HIV infection (CD4+ T cell levels persistently < 100 cells/μL during the last 6 months and HIV RNA persistently detectable during the last 3 months) (1C).
Non-compliance with anti-retroviral therapy (1D).
Positive CDC crossmatch (1D).
Anti-HIV drug resistance and lack of future HIV treatment options (1D).
Previous or current infections that are at high risk of re-activating with immune suppression: –
• Aspergillus – infection or colonisation
• Any multi-resistant fungal infections
• Cytomegalovirus (CMV) disease with any activity and unresponsive to first line therapy.
• Influenza or RSV infection within 30 days
• Active bacterial infections
• Mycobacterial infections – unless there is clear evidence of successful treatment
Advanced cardiopulmonary disease
History of neoplasms except solid tumours adequately treated and disease-free survival documented for > five years (consult IPTTR pre-listing)
HTLV-1 positive patients
Patients with significant human papilloma virus (HPV) associated advanced cervical and anal intraepithelial neoplasia (CIN/AIN III) and carcinoma in situ need to be excluded.
Hepatic cirrhosis (F4 fibrosis by Metavir if HBV/HCV co-infection) and evidence of active viral replication if HBV/HCV co-infected
Pregnancy.
Continuing use of illicit recreational drugs (Recreational drugs include analgesics, depressants, stimulants, and hallucinogens.)
BTS Guidelines:
Selection and assessment before transplantation.
Patients with HIV-infection are unsuitable to be living kidney donors. (1D)
HIV-positive patients are wait-listed only if:
a) They are concordant with treatment, particularly cART therapy. (1D)
b) Their CD4+ T cell counts are >100 cells/µL (ideally > 200 cells/ µL) and have been stable during the previous 3 months. (1B)
c) HIV RNA has been undetectable during the previous 6 months. (1B)
d) No opportunistic infections have occurred during the previous 6 months. (1B)
e) They have no history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma. (1B)
Consent and confidentiality:
Existing guidelines on the ethics of deceased donor and living donor transplantation are followed for all transplantation involving people with HIV disease. (Not graded)
The standard of consent for HIV-positive transplant candidates is the same as for any other transplant. (Not graded)
Transplant teams must be satisfied that donor consent is adequate and that procedures for ensuring this are transparent and established in advance. (Not graded)
Wherever possible, the recipient is encouraged to disclose their diagnosis of HIV to their donor. (Not graded)
All living donors are asked whether there are any medical conditions that would cause them to change their decision to donate, without highlighting HIV. (Not graded)
All living donors are made aware that there may be medical and social information about the recipient that is not disclosed. (Not graded)
All living donors are asked to acknowledge that they are aware that they will not be given confidential information about the recipient which is not deemed relevant to the outcome of the kidney transplant (Not graded)
Screening before transplantation:
All transplant candidates undergo careful immuno-virological and antiretroviral status review. This includes CD4 cell count, HIV RNA level, current and prior antiretroviral therapies, HLA-B5701 status and HIV resistance profile. (1D)
Patients with HIV RNA levels < 200 copies/mL may be considered suitable for solid organ transplantation if otherwise well and fully adherent with their medications. (1C)
Transplant candidates undergo serologic testing for syphilis, herpes simplex virus, Epstein-Barr virus, cytomegalovirus, varicella zoster virus, human T-cell leukaemia virus and Toxoplasma gondii. (1D)
Transplant candidates are tested for latent Mycobacterium tuberculosis infection with an interferon-gamma test with or without a concurrent Mantoux test following the testing strategy for immunocompromised patients in the current NICE Tuberculosis Guidelines. (1C)
Transplant candidates who test positive for latent Mycobacterium tuberculosis infection are assessed for any evidence of active tuberculosis disease. (1C)
Transplant candidates with evidence of active tuberculosis disease are treated according to current NICE guidance prior to transplantation. (1C)
Transplant candidates with latent Mycobacterium tuberculosis infection, in whom active disease has been excluded are treated for latent Mycobacterium tuberculosis infection, according to current NICE TB guidelines, prior to transplantation. (1C)
All transplant candidates are screened for viral hepatitis. Those found to be hepatitis B surface antigen or hepatitis C antibody positive should have their hepatitis B DNA / hepatitis C RNA levels quantified and be investigated for the presence of liver cirrhosis. (1C)
All hepatitis B surface antigen positive patients who are wait listed for solid organ transplantation receive treatment to ensure hepatitis B DNA is fully suppressed(1B).
Patients considered for solid organ transplantation are assessed for the presence of cervical and/or anal neoplasia; those with advanced cervical/anal intraepithelial neoplasia (CIN/AIN III) or carcinoma in situ should receive treatment prior to transplantation. (1D)
Pre-transplant immunization:
Hepatitis B virus (HBV) vaccine is administered to all non-immune patients (HBV surface antibody titres < 10 mIU/mL). (1B)
Hepatitis A virus (HAV) vaccine is administered to all non-immune patients. (1D)
Pneumococcal polysaccharide vaccine (PPV-23) is administered to all patients. (1B)
Varicella zoster vaccine (VZV) vaccine is administered to non-immune patients with CD4 cell counts >200 cells/µL. (1C)
Influenza vaccine is administered annually to patients awaiting solid organ transplantation. (1B)
Diphtheria, tetanus and pertussis (DTP) vaccine is administered to all patients. (2D)
Measles, mumps and rubella (MMR) vaccine is administered to all patients who are nonimmune to measles. (2D)
Human papilloma virus (HPV) vaccine is offered to patients at risk of HPV acquisition. (2C)
Post-transplant prophylaxis:
HIV-positive transplant recipients receive lifelong prophylaxis against Pneumocystis pneumonia following transplantation. (1D)
Prophylaxis against cytomegalovirus is indicated in CMV seronegative recipients of organs from CMV seropositive donors for a minimum of 3 months. (1A)
CMV seropositive transplant recipients receive either prophylaxis against CMV infection or PCR surveillance and pre-emptive therapy for a minimum of 3 months. (1A)
Transplant patients who are well and were not assessed and treated for Mycobacterium tuberculosis latent infection or disease before transplantation should be assessed as recommended for patients prior to transplantation. (1C)
-Transplant patients who are well and were assessed and treated for Mycobacterium tuberculosis latent infection or disease before transplantation do not need reassessment for Mycobacterium tuberculosis latent infection unless there is a new history of exposure to tuberculosis. (1C)
Transplant patients who are re-exposed to tuberculosis after transplantation should be assessed for Mycobacterium tuberculosis latent infection and/or disease as recommended in current NICE TB guidance on tuberculosis contact tracing. (1C)
Toxoplasma IgG seropositive recipients with a CD4+ count < 200 cells/µL or any recipient of an organ from a donor seropositive for toxoplasmosis receive lifelong prophylaxis. (2C)
Prophylaxis against Mycobacterium avium complex (MAC) is indicated when the CD4+ ≤ 50 cells/µL, and it be stopped when the CD4 count is >100 cells/µL for 6 months. (2D)
Monitoring of HIV virological control:
Quantitative HIV RNA and CD4+ T-cell counts are measured regularly, with the first assays at 1 month after transplant and subsequent studies every 2-3 months for the first year then every 3-6 months thereafter. (1B)
If patients have persistent HIV viraemia, drug-resistance testing is carried out to determine treatment options. (1D)
More frequent monitoring of CD4 count may be necessary in patients receiving depleting antibodies to determine the need for anti-infective prophylaxis. (2D)
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Yes, I will proceed to transplantation as DSA positive is not a
contraindication for transplantation, with this low MFI to A36 – (found in
African)
The greater incidence of rejection episodes can be explained if (FCXM positivity is a relative contraindication for HIV transplant).
HIV-positive kidney transplant recipients are treated similarly to HIV-negative recipients, with pre-transplant vaccines and post-transplant CMV treatment.
The transplant procedure should not be prevented by the presence of DSA, but MFI values more than 2000 are significant and may not be well correlated with allograft outcomes.
I will counsel the patient about it and inform him or her that he is immunologically at high risk of being HIV positive due to immune dys-regulation. This is done to rule out co-infection in the recipient, whether it be HIV/HBV or HIV/HCV.
I will continue with the transplantation, followed by IL 2RA (Basiliximab) induction and triple immune suppression maintenance (CNIs, MMF, and Prednisolone).
It should be to do post-transplant DSA monitoring, biopsy, and other parts of treatment such routine HIV RNA monitoring, immunizations, and long-term PCP prevention.
Reference:
British Transplantation Society Guidelines (BTS) kidney and pancreas transplantation in patients with HIV March 2015 [Minor Revision January 2017] Second Edition.
Sawinski D. Kidney Transplantation in Patients with HIV. Kidney360. 2020;1(7):705-711. Published 2020 May 6. doi:10.34067/KID.0002112020
Thankyou you reviewed the HOPE guidelines and the BTS guidelines
What are your decisions?
This is a DBD donor who is HIV positive and has good kidney function
Being HIV positive, the organs can only be offered to HIV positive recipients
A history of his HIV disease and treatment should be sought to assess if he has had treatment failure due to the risk of HIV superinfetion
The potential recipient should be counseled that he is getting an HIV positive donors organ
The potential recipient should:
If the donor was a live donor and if the recipient was HIV positive:
For the recipient
For a DSA positive with MFI 1550 and negative flow cytometry:
I would still proceed with the transplant
The question would arise about the choice of the induction agent: ATG versus basiliximab
ATG has been shown to be superior for reducing the rejection episodes but in HIV positive recipients, it will lower the CD4s for a prolonged duration with a hypothetical risk of increased opportunistic infections. However, some studies reported no increased risk of increased opportunistic infection and lower rates of rejection.
I would go for ATG induction
The maintenance ISS would be tacrolimus based with close monitoring of the drug levels
The patient should be assessed for latent TB before transplant and if present should be treated appropriately
He should receive prophylaxis for PJP and CMV
Organ transplantation in persons with HIV AIDS 2020, 34:1107–1116
The donor is a high risk of developing HIVAN so you should test for proteinuria and biopsy.
Will you accept this DBD donor?
I will accept this donor only if the recipient is also HIV positive and have following perquisites.
For Donor
HIV viral load <50 copies/mL
CD4 count >200/μL for at least 6 months prior to brain injury
Information about the donor virus (genotype patterns) where possible & current viral load
Absence of H/O virological failure or drug resistance (1D)
And HIVAN is excluded.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes, I will accept him on following ground.
Patients with HIV infection have the same access to living donor kidney transplantation as non-infected patients (1B)
Potential donors for patients with HIV infection are informed of medical, surgical, and psychosocial factors that may heighten the recipient’s morbidity and mortality risk, but that disclosure of the recipient’s HIV status is not mandatory (Not graded)
Patients with HIV-infection are unsuitable to be living kidney donors (1D)
Prerequisite for For Donor
-HIV viral load <50 copies/mL
-CD4 count >200/μL for at least 6 months prior to donation
-now about the donor virus (genotype patterns) where possible & current viral load.
-Need to know absence of H/O virological failure or drug resistance (1D)
-Have to exclude HIVAN.
Prerequisite For recipient
-Undetectable HIV viral load for previous 6 months
-C4D count > 200 cells /ml and stable for more than previous 3 months
-Is compliance with cART
-No evidence of active opportunistic infections for at least the last 6 months
-No evidence of HIV-associated malignancy
-Ability to have a close follow-up for immunosuppression, drug-level monitoring, and management
-The recipients are counselled & give informed consent both at the time of listing & at the time of transplantation (1D)
-The transplant center should have experience in transplanting HIV+ patients (Not graded)
Will take history regarding vaccination and natural infection and investigation to exclude the disease.
Vaccination: DTP, MMR, pneumococcal, hemophilus influenza, Meningococcus, Influenza, VZV, hepatitis A, B, HPV,
Infection: strongyloidosis, syphilis, herpes simplex virus, Epstein-Barr virus, cytomegalovirus, human T-cell leukaemia virus, and Toxoplasma gondii, hepatitis b, c, latent tuberculosis, microbacterium avium
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
In this case the patient is consider as standard risk so, I will proceed with tacrolimus, MMF & prednisolone maintenance therapy and Induction with Basiliximab.
The prerequisite of donor and recipient and screening of infection is as of answer to question 2
Need to Monitor
Quantitative HIV RNA and CD4+ T-cell counts are measured regularly, with the first assays at 1 month after transplant and subsequent studies every 2-3 months for the first year then every 3-6 months thereafter (1B)
If patients have persistent HIV viraemia, drug-resistance testing is carried out to determine treatment options (1D
Drugs
Pre-emptive switching away from boosted protease-inhibitors (PI)-based antiretroviral regimens, if alternatives exist, in order to minimize drug interactions (2D)
A dose-finding trial of calcineurin-inhibitors prior to solid organ transplantation in order to determine optimum doses to initiate post-transplant (2D)
IL2R blocker as induction
Post-transplant prophylaxis
Pneumocystis pneumonia (1D)
Cytomegalovirus is indicated in CMV seronegative recipients of organs from CMV seropositive donors for a minimum of 3 months (1A)
CMV seropositive transplant recipients receive either prophylaxis against CMV infection or PCR surveillance and pre-emptive therapy for a minimum of 3 months (1A)
Toxoplasma IgG seropositive recipients with a CD4+ count <200 cells/µL or any recipient of an organ from a donor seropositive for toxoplasmosis receive lifelong prophylaxis (2C)
Prophylaxis against Mycobacterium avium complex (MAC) is indicated when the CD4+ count is ≤ 50 cells/µL, and it be stopped when the CD4 count is >100 cells/µL for 6 months (2D)
References
1.British Transplantation Society Guidelines. Kidney & Pancreas Transplantation in Patients with HIV March 2015 [Minor Revision January 2017]
2.Prof. Ahmed Halawa lecture on HIV
You accepted the live HIV donor and later stated all the expected problems he is waiting for ,concluding he is not a safe choice!
Yes prof. He can be accepted as donor as there is no contraindication but he is not a safe choice.
Will you accept this DBD donor?
For the indexed case of HIV-positive DD yes I will accept him for HIV-positive recipients only provided the recipient accepts the offer and has been counseled earlier and get consented, and he medically fits the eligibility criteria for transplantation including he is not in active viremia with confirmed negative viral load < 50 copies, C4D count > 200cells/ml for the last 6 months, no evidence of active infection or active malignancy, well adherence to antiviral therapy and no history of drug-resistant. Recipients should routinely be screened for tuberculosis, syphilis, and hepatitis C pre-transplant. Similarly, in places with epidemiologic risks, strongyloidiasis screening may be needed.Treatment/screening for co-infection for HBV/HCV should be done prior to transplant.
PWH can donate organs to HIV +VE recipients waiting for kidney or liver transplants in research settings in the US through the HOPE act HIV DD eligibility criteria for a donation. Includes HIV donor-specific data from the HIV specialist such as ART history, HIV genotypic testing, C4D cell counts, HIV viral load results, and history of opportunistic complications, so that donor suitability can be established.
Discuss with the recipient the option of the IS and should be on a stable dose of ART for at least 3 months before transplantation some preferred to avoid the use of protease inhibitors due to severe drug interaction with CNI and m TOR inhibitors that put the patient at risk of rejection with underdosing or drug toxicity with overdosing. better outcomes had been reported with integrase strand transfer inhibitor-based antiretroviral regimens. As these regimens have no interaction with calcineurin inhibitors, However, integrase inhibitors are not available worldwide and people still used PI as CNI-sparing agents and reduce the drug cost which is the common practice in Africa. we need combined care and follow-up with HIV specialist and transplant team with frequent monitoring of viral load and C4d count especially during treatment for acute rejection also avoid fixed drug combination as it can be associated with increased risk of AKI and need prolonged chemoprophylaxis for PJP, CMV, fungal infection
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
using HIV-infected live donors is not recommended and evidence is very limited to case reports, as they are at risk of wide range of renal diseases including HIVAN, glomerular diseases like FSGS, IC – mediated MGN, MPGN, tubulointerstitial nephritis, drug and viral-related metabolic effects, and nephrotoxicity. However, there is a reduction in HIV-related CKD with the use of ART and according to recent studies, the prevalence of chronic kidney disease among HIV-infected patients receiving treatment is between 8% and 22% (2).The decision should be individualized case by case and center-based policy to accept such donors provide they have good experience and includes a stable HIV course donors with no proteinuria and a kidney biopsy confirm no evidence of HIVAN, no DM or hypertension, and a normal BMI
HIV-positive African American persons with high-risk apoprotein L1 (APOL1) genotypes are at risk for the development of HIVAN and focal segmental glomerulosclerosis
based on the limited evidence i would not accept donation from alive HIV +ve patient , donor referred to healthy person not have medical complications
.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
HIV-positive recipients reported a higher rate of rejection based on the evidence around 15% in the first year then 20% in 2 years and even 30% after3 years, mostly due to the drug-drug interaction and inconsistency of the drug levels which is more with PI ART so for this patient with already have a low titer of preformed DSA for HLA A36 needs frequent monitoring and use of integrase inhibitors based ART would be safer after transplantation and go ahead with the transplantation providing his FXCM negative, induction still can go with basiliximab vs ATG followed by triple IS including tacrolimus, MMF, prednisolone
References
1. Kumar RN, Stosor V. Organ transplantation in persons with HIV. AIDS. 2020 Jul 1;34(8):1107-1116.
2. Muller E, Barday Z, Kahn D. HIV-positive-to-HIV-positive kidney transplantation. N Engl J Med. 2015 May 21;372(21):2070-1
3.Muller E, Botha FCJ, Barday ZA, Manning K, Chin-Hong P, Stock P. Kidney Transplantation in HIV-positive Patients: Current Practice and Management Strategies. Transplantation. 2021 Jul 1;105(7):1492-1501.
Well done your decisions are clear and wise, ART are well chosen when available.
It is CD4 not C4D!
sorry yes CD4
Thank you prof Dawlat
Will you accept this DBD donor?
HIV-positive dialysis patients had better survival and morbidity, although antiretroviral medication administration is complicated.
Stable HIV-positive people can receive kidney and liver transplants.
Although cadaveric and live-related donor kidney transplant patients with HIV had equivalent graft and patient longevity, there are still difficulties.
In this particular case, only HIV-positive recipients will be accepted.
HIV-infected organs should only be transplanted from deceased donors with following charachteristics:
HIV <50 copies/mL
CD4 count >200/μL
No history of opportunistic infections in the last 6 months
No history of virological failure or medication resistance
Counseling and informed consent are recommended at listing and transplantation
The transplant center should have HIV+ transplant experience
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
HIV-infected organs should only be transplanted from the following types of deceased donors:
– HIV 50 copies/mL – CD4 count >200/L – No history of opportunistic infections in the previous six months – No history of virological failure or drug resistance
– Counseling and informed consent are advised at the time of listing and transplantation
All HIV transplants follow deceased donor and living donor ethics requirements.
HIV-positive transplant candidates must consent as usual.
Transplant teams must be confident with donor consent and its protocols.
-Recipients should inform donors of their HIV status whenever possible.
Living donors are informed that recipient medical and social information may be preserved.
All living donors must agree that they will not receive confidential recipient information that is not essential to the kidney donation.
Candidates for organ transplants are screened for syphilis, herpes simplex virus, Epstein-Barr virus, cytomegalovirus, varicella zoster virus, human T-cell leukaemia virus, and Toxoplasma gondii.
Transplant candidates are screened for latent Mycobacterium TB infection using an interferon-gamma test with or without a concomitant Mantoux test, in accordance with the testing strategy for immunocompromised patients outlined in the current NICE Tuberculosis Guidelines.
Individuals who are candidates for solid organ transplantation are evaluated for the presence of cervical and/or anal neoplasia; those with advanced cervical/anal intraepithelial neoplasia (CIN/AIN III) or carcinoma in situ should be treated prior to transplantation.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Positive flow cytometric cross-match and blood-type incompatibility are contraindications to kidney transplantation in patients with HIV, but FCXM is negative and blood group compatible.
At the time of transplantation, all HIV-positive patients who are eligible for a kidney transplant are administered induction therapy.
Basiliximab is administered to the majority of HIV-positive patients undergoing induction therapy.
After kidney transplantation, HIV-positive patients get triple therapy maintenance immunosuppression consisting of steroids, a CNI, and an antiproliferative drug.
HIV-positive kidney transplant recipients are treated for acute rejection in the same manner as HIV-negative kidney transplant recipients.
-Preemptive switching away from antiretroviral regimens based on boosted protease inhibitors, if alternatives exist, in order to minimize medication interactions.
Excellent Mohamed
Do not forget to exclude HIVAN in the potential donor.
Will you accept this DBD donor?
For HIV/AIDS patients with advanced organ disease, organ transplantation may be their only chance at extending their lives.
It is advised that only dead donors’ organs with the following characteristics should be used for transplantation utilizing organs from HIV-infected people:
Prior to brain damage, HIV viral load was 50 copies/mL and CD4 count was >200/L for at least 6 months.
Where possible, details about the donor virus’s genetic makeup and current viral burden.
Absence of medication resistance or H/O virological failure.
It is advised that recipients receive counselling and provide informed consent both before being listed and after receiving a transplant.
The transplant centre needs to have knowledge of HIV+ individuals undergoing transplants.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
The HOPE Act also allows people with HIV to be living donors.
Yeah, I will accept him with the aforementioned requirements.
Meet all transplant centre requirements.
Have a CD4 count of more than 500 and an undetectable viral load.
Possess no prior history of an invasive infection, such as current fungal meningitis or PCP pneumonia.
Proceed with a kidney biopsy.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
In patients with HIV, a positive complement-dependent cytotoxic (CDC) cross-match is an absolute bar to kidney donation; however, a positive flow cytometric cross-match is not (FCXM).
Relative contraindications to kidney transplantation include blood type incompatibility:
Although the presence of DSA shouldn’t stop the transplant surgery, MFI values over 2000 are important and may not be favourably linked with allograft outcomes.
I will discuss it with the patient and let him or her know that due to immune dysregulation, he is immunologically at high risk of being HIV positive.
This is done to rule out co-infection, whether it be HIV/HBV or HIV/HCV, in the recipient.
The ability to perform post-transplant DSA monitoring, biopsies, and other treatment components including routine HIV RNA monitoring, vaccinations, and long-term PCP prophylaxis should be possible.
REFERENCES;
British Transplantation Society Guidelines. Kidney & Pancreas Transplantation in Patients with HIV March 2015 [Minor Revision January 2017]
HOPE Act On November 19 and 21, 2015,
Kidney Transplantation in Patients with HIVDeirdre Sawinski
Solid organ transplantation in the HIV-infected patient: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice Emily A Blumberg , Christin C Rogers
Thank you, Dr Muhammed
You ran away from question number 3. What is your management plan?What induction you would use and why?
Induction therapy
The majority of HIV-positive patients receiving induction therapy are given basiliximab.
HIV-positive kidney transplant recipients receive triple therapy maintenance immunosuppression, consisting of steroids, a CNI, and an antiproliferative drug.
HIV-positive kidney transplant recipients receive the same treatment as HIV-negative recipients.
British Transplantation Society Guidelines. Kidney & Pancreas Transplantation in Patients with HIV March 2015 [Minor Revision January 2017]
Will you accept this DBD donor?
===========================
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
===========================
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
References
Thank you, Mohamed
ATG or Basiliximb if the recipient has DSA, but negative crossmatch?
You have to take a decision and should be able to justify it.
4. You were offered kidneys from a 51-year-old male DBD (donor after brain stem death) donor who suffered from SAH (grade 5) complicating cerebral aneurysm. Her retrieval S Cr was 78 µmol/L. Virology was reported negative for both HBV and HCV, but HIV is positive.
====================================================================
Will you accept this DBD donor?
History
Yes I will accept this donor
====================================================================
Would you accept this donor as a live donor if the recipient is also HIV positive?
If yes, what are the conditions that should be met?
The HOPE Act also allows with HIV to be living donors. To become an HIV-positive living donor, you must:
====================================================================
All potential kidney transplant recipients are screened for HIV infection (1D)
====================================================================
Relative contraindications to kidney transplantation:
====================================================================
The following should be considered absolute contraindications:
====================================================================
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
====================================================================
Reference
Thank you, Dr Mahmoud, for the excellent answer. Do not forget to exclude HIVAN in the donor (biochemical of even biopsy).
Many thanks you for your support and advice.Prof. Halwa
51 years old DBD donor, positive for HIV, and negative hepatitis B and C screen, with normal kidney function.
Will you accept this DBD donor?
Yes, I’ll accept this donor to HIV infected recipient after fulfilling the following criteria:
Viral load 200/ml or more for at least 6 months before the brain injury.
Excluding HIVAN by absence of proteinuria and a kidney biopsy.
With continuation of HAART after transplant and the recipient fit for intervention.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes, I would accept this living HIV donor if he fulfill the following criteria: (HIV Organ Policy Equity Act- 2013)
· The viral load is undetectable or less than 50 sopie/ml and CD4> 200 for the last 6 months.
· No evidence of HIV associated nephropathy by performing a kidney biopsy, and checking for proteinurea.
· Has no evidence of invasive infection, PCP, or active fungal meningitis.
· Meet all the requirement of the transplant center.
And the recipient should fulfill the following criteria:
· Fit with life expectancy of > 5 yrs
· Concordant with HAART therapy (1D)
· CD4+ T cell counts are >100 cells/μL (ideally > 200 cells/ μL) and have been stable during the previous 3 months (1B).
· Fully HIV RNA load and CD4 > 100 (2C).
· HIV RNA undetected or less than 50 copies/ml for the last 6 months (1B).
· No history of opportunistic infection for the last 6 months (1B).
· No history of PML (Progressive multifocal leukoencephalopathy) , chronic intestinal cryptosporidiosis, or lymphoma (1B).
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
Yes, I will proceed to transplantation as DSA positive is not a contraindication for transplantation, with this low MFI to A36 – ( found in African)
The contraindications are:
Absolute:
Uncontrolled HIV infection (CD4+ T cell levels persistently < 100 cells/μL during the last 6 months and HIV RNA persistently detectable during the last 3 months) (1C).
Non-compliance with anti-retroviral therapy (1D).
Serious ongoing or recurring infection, including documented history of PML (1D).
Positive CDC crossmatch (1D).
Pregnancy (1D).
Anti HIV drug resistance and lack of future HIV treatment options (1D).
Relative:
Positive FCXM (mainly T-cell positive) (1D).
ABOi (2D).
Treated malignancy, including extra[1]cutaneous Kaposi sarcoma (2C).
Chronic liver disease (cirrhosis, chronic HBV or HCV or persistently abnormal liver function testing) (2D). Marked obesity (BMI>35kg/m2) (2D).
HTLV infection (due to the risk of developing leukemia) (1D).
References:
(1) Blumberg EA, Rogers CC; American Society of Transplantation Infectious Diseases Community of Practice. Solid organ transplantation in the HIV-infected patient: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13499. doi: 10.1111/ctr.13499. Epub 2019 Apr 21. PMID: 30773688.
(2) BTS kidney and pancreas transplantation in patients with HIV-2017.
Thank you, Dr Mohamed
You ran away from question number 3. What is your management plan?
Thank you Prof. Ahmad
i would give an induction with basiliximab not an ATG
and give CNI based tripple maintenance therapy
Thank you, Dr Mohamed
1-Will you accept this DBD donor?
Yes; I will accept this HIV + deceased Donor after counseling recipient patient.
According BTS Guidelines;
–HIV per se is not a contraindication for kidney transplantation. (1B)
-Recipients are counselled and give informed consent both at the time of listing and at the time of transplantation. (1D)
-HIV+ organ use is restricted to those centres that have experience in transplanting HIV+ patients. (Not graded)
-Transplantation using organs from HIV-infected individuals is restricted to organs from deceased donors with:
a) HIV viral load < 50 copies/mL and CD4 count > 200/µL for at least 6 months prior to brain injury,
b) Information about the donor virus such as historical genotype patterns where possible and current viral load,
c) No history of virological failure or drug resistance. (1D)
2-Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Yes; I will accept this living donor (D+HIV / R+HIV)
But if R-HIV, I will not accept this D+HIV
According BTS Guidelines;
Selection and assessment before transplantation
-Patients with HIV-infection are unsuitable to be living kidney donors. (1D)
-HIV-positive patients are wait-listed only if:
a) They are concordant with treatment, particularly cART therapy. (1D)
b) Their CD4+ T cell counts are >100 cells/µL (ideally > 200 cells/ µL) and have been stable during the previous 3 months. (1B)
c) HIV RNA has been undetectable during the previous 6 months. (1B)
d) No opportunistic infections have occurred during the previous 6 months. (1B)
e) They have no history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis, or lymphoma. (1B)
Consent and confidentiality;
-Existing guidelines on the ethics of deceased donor and living donor transplantation are followed for all transplantation involving people with HIV disease. (Not graded)
-The standard of consent for HIV-positive transplant candidates is the same as for any other transplant.(Not graded)
-Transplant teams must be satisfied that donor consent is adequate and that procedures for ensuring this are transparent and established in advance. (Not graded)
-Wherever possible, the recipient is encouraged to disclose their diagnosis of HIV to their donor. (Not graded)
-All living donors are asked whether there are any medical conditions that would cause them to change their decision to donate, without highlighting HIV. (Not graded)
-All living donors are made aware that there may be medical and social information about the recipient that is not disclosed. (Not graded)
-All living donors are asked to acknowledge that they are aware that they will not be given confidential information about the recipient which is not deemed relevant to the outcome of the kidney transplant (Not graded)
Screening before transplantation;
-All transplant candidates undergo careful immuno-virological and antiretroviral status review. This includes CD4 cell count, HIV RNA level, current and prior antiretroviral therapies, HLA-B5701 status and HIV resistance profile. (1D)
-Patients with HIV RNA levels < 200 copies/mL may be considered suitable for solid organ transplantation if otherwise well and fully adherent with their medications. (1C)
-Transplant candidates undergo serologic testing for syphilis, herpes simplex virus, Epstein-Barr virus, cytomegalovirus, varicella zoster virus, human T-cell leukaemia virus and Toxoplasma gondii. (1D)
-Transplant candidates are tested for latent Mycobacterium tuberculosis infection with an interferon-gamma test with or without a concurrent Mantoux test following the testing strategy for immunocompromised patients in the current NICE Tuberculosis Guidelines. (1C)
-Transplant candidates who test positive for latent Mycobacterium tuberculosis infection are assessed for any evidence of active tuberculosis disease. (1C)
-Transplant candidates with evidence of active tuberculosis disease are treated according to current NICE guidance prior to transplantation. (1C)
-Transplant candidates with latent Mycobacterium tuberculosis infection, in whom active disease has been excluded are treated for latent Mycobacterium tuberculosis infection, according to current NICE TB guidelines, prior to transplantation. (1C)
-All transplant candidates are screened for viral hepatitis. Those found to be hepatitis B surface antigen or hepatitis C antibody positive should have their hepatitis B DNA / hepatitis C RNA levels quantified and be investigated for the presence of liver cirrhosis. (1C)
-All hepatitis B surface antigen positive patients who are wait listed for solid organ transplantation receive treatment to ensure hepatitis B DNA is fully suppressed. (1B)
-Patients considered for solid organ transplantation are assessed for the presence of cervical and/or anal neoplasia; those with advanced cervical/anal intraepithelial neoplasia (CIN/AIN III) or carcinoma in situ should receive treatment prior to transplantation. (1D)
Pre-transplant immunization:
-Hepatitis B virus (HBV) vaccine is administered to all non-immune patients (HBV surface antibody titres < 10 mIU/mL). (1B)
-Hepatitis A virus (HAV) vaccine is administered to all non-immune patients. (1D)
-Pneumococcal polysaccharide vaccine (PPV-23) is administered to all patients. (1B)
-Varicella zoster vaccine (VZV) vaccine is administered to non-immune patients with CD4 cell counts >200 cells/µL. (1C)
-Influenza vaccine is administered annually to patients awaiting solid organ transplantation. (1B)
-Diphtheria, tetanus and pertussis (DTP) vaccine is administered to all patients. (2D)
– Measles, mumps and rubella (MMR) vaccine is administered to all patients who are nonimmune to measles. (2D)
-Human papilloma virus (HPV) vaccine is offered to patients at risk of HPV acquisition. (2C)
Post-transplant prophylaxis;
-HIV-positive transplant recipients receive lifelong prophylaxis against Pneumocystis pneumonia following transplantation. (1D)
-Prophylaxis against cytomegalovirus is indicated in CMV seronegative recipients of organs from CMV seropositive donors for a minimum of 3 months. (1A)
-CMV seropositive transplant recipients receive either prophylaxis against CMV infection or PCR surveillance and pre-emptive therapy for a minimum of 3 months. (1A)
-Transplant patients who are well and were not assessed and treated for Mycobacterium tuberculosis latent infection or disease before transplantation should be assessed as recommended for patients prior to transplantation. (1C)
-Transplant patients who are well and were assessed and treated for Mycobacterium tuberculosis latent infection or disease before transplantation do not need reassessment for Mycobacterium tuberculosis latent infection unless there is a new history of exposure to tuberculosis. (1C)
-Transplant patients who are re-exposed to tuberculosis after transplantation should be assessed for Mycobacterium tuberculosis latent infection and/or disease as recommended in current NICE TB guidance on tuberculosis contact tracing. (1C)
-Toxoplasma IgG seropositive recipients with a CD4+ count < 200 cells/µL or any recipient of an organ from a donor seropositive for toxoplasmosis receive lifelong prophylaxis. (2C)
-Prophylaxis against Mycobacterium avium complex (MAC) is indicated when the CD4+ ≤ 50 cells/µL, and it be stopped when the CD4 count is >100 cells/µL for 6 months . (2D)
Monitoring of HIV virological control;
-Quantitative HIV RNA and CD4+ T-cell counts are measured regularly, with the first assays at 1 month after transplant and subsequent studies every 2-3 months for the first year then every 3-6 months thereafter. (1B)
-If patients have persistent HIV viraemia, drug-resistance testing is carried out to determine treatment options. (1D)
-More frequent monitoring of CD4 count may be necessary in patients receiving depleting antibodies to determine the need for anti-infective prophylaxis. (2D)
3-Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
–Positive complement-dependent cytotoxic (CDC) cross-match. (1D) is absolute contraindications to kidney transplantation in patients with HIV; But
-Positive flow cytometric cross-match (FCXM). (1D)
-Blood-type incompatibility. (2D) are relative contraindications to kidney transplantation:
And regarding Induction and maintenance immunosuppression will follow (BTS Guidelines)
-All HIV-positive patients eligible for kidney transplantation are offered induction therapy at the time of transplantation. (1C)
-For the majority of HIV-positive patients induction therapy is with an interleukin-2 receptor antagonist (IL-2RA). (1B)
-HIV-positive patients are given triple therapy maintenance immunosuppression started at the time of kidney transplantation, including steroids, a calcineurin inhibitor (CNI) and an anti-proliferative agent. (1C)
-Acute rejection is treated in HIV-positive kidney transplant recipients in the same way as HIV-negative kidney transplant recipients. (2D)
-Pre-emptive switching away from boosted protease-inhibitors (PI)-based antiretroviral regimens, if alternatives exist, in order to minimise drug interactions. (2D)
-Antiretrovirals with nephrotoxic potential (specific tenofovir formulations and atazanavir) are avoided in the setting of kidney transplantation if suitable alternatives are available. (Not graded)
-Antiretrovirals with significant drug-drug interactions with calcineurin inhibitors (ritonavir and cobicistat) are avoided in the setting of solid organ transplantation if suitable alternatives are available. (2D)
References;
British Transplantation Society Guidelines;March 2015 [Minor Revision January 2017].
This is not a focused answer, just a copy and paste from the guidelines. Please answer the questions asked above in. You are hitting a fly with a cannon ball.
Thanks, our Prof and sorry for details.
Q1;
Yes; I will accept this HIV + deceased Donor after counseling recipient patient.
Q2;
Yes; I will accept this living donor (D+HIV / R+HIV) and to R/O D+ HIV AN by kidney biopsy.
But if R-HIV, I will not accept this D+HIV
Q3;I will give induction an interleukin-2 receptor antagonist (IL-2RA) & maintenance protocol as triple therapy immunosuppression started at the time of kidney transplantation, including steroids, a calcineurin inhibitor (CNI) and an anti-proliferative agent.
and keep in mind drug interaction between HAART & CNI,
If the recipient is HIV positive , then donation from HIV positive donor is advised and recommended as per National kidney foundation Hope Act made on 2013. Its recommended to have lower HIV viral load and CD4 count more than 500 in the cadaveric donor . However, no cut off value is clearly indicative for selection.
According to the same Hope Act living donation is possible to an HIV positive recipient.
Conditions for accepting HIV living organs donation:
1]maintaining the standards of transplant center.
2]Viral load has to be undetectable
3] C4D count exceeds 500.
4] Negative past history of invasive infection such as PCP pneumonia and fungal meningitis .
Recipient with DSA against A36 with MFI of 1550:
As far as FCXM is negative , There is minimal risk of acute rejection and hyperacute rejection. However pre-formed DSAs titer has to be followed up regularly along with allograft function. Additionally, characterization of IgG DSAs might be considered , with C1q test to assess for complement fixing property and IgG analysis to identify subtypes .
Anti rejection must be optimized with ATG induction and Tacrolimus based maintenance protocol.
References:
1] National Kidney foundation. HIV and Kidney Transplantation/Donation.
2]Peter S. Yoo et al. Clinical outcomes among renal transplant recipients with pre-transplant weakly-reactive donor specific antibodies.Clin Transplant. 2014 Jan; 28(1): 127–133.
In potential HIV living donor , Kidney biopsy must be performed*
Thank you, Wael
Agree with the kidney biopsy, but do you still give ATG just because of the DSA while crossmatch is negative? Remember, there is no strong evidence. It is a high-risk transplant. Which one is more important, a functioning kidney or a patient dying from infection?
Q1.
Q2.
Q3.
Source:
-BTS guidelines 2018
-Organ transplantation in persons with HIV by Rebecca N. Kumar and Valentina Stosor
Thank you, Ben
Agree with your management plan. I would not give ATG or perform desensitisation in an HIV patient with negative crossmatch. I rather monitor and see what happens.
Yes, thnxs prof
Will you accept this DBD donor?
Yes, I would accept this HIC positive donor only if the recipient is also HIV positive.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
BTS guidelines say:
“Patients with HIV-infection are unsuitable to be living kidney donors”
While there are many reports on HIV+ve to HIV+ve transplant.
The HIV+ve living donor can be accepted for HIV+ve recipient if :
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
BTS guidlines: Kidney & Pancreas Transplantation in Patients with HIV
Thank you, Abhijit
Agree with your management plan. I would not give ATG or perform desensitisation in an HIV patient with negative crossmatch. I rather monitor and see what happens.
1- yes will accept if there is no other option
2- yes will accept in the following conditions:
a- on ART
b-CD4 count more than 100 or 200 with stability over the previous 3 months
c-PCR HIV less than 50 copies per ml stable over previous 6 months
d-no history of opportunistic infections in the last 6 months
e-no history of PML, chronic intestinal cryptosporidiosis or lymphoma
i- as regard donor, should search for any factors leads to CKD like DM, HTN, HIVAN, FSGS.
3-i think the plan will be induction by basiliximab, maintenance by tacrolimus, MMF, and prednisolone
reference:
lecture of prof Ahmed Halawa
Thank you, Riham
WI agree with your management plan. BUT are you concerned about HIVAN in the donor.
You should add more references.
Will you accept this DBD donor?
Yes, I will accept this DBD if the recipient is HIV +
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
Though live donation was absolutely contraindicated due to the risk of CKD, the ability to use them will make more organs available and reduce the waiting list. However, another important concern is that a limited number of cases have been done which makes it more difficult to have a holistic view of the outcome of such a procedure
Yes if the following criteria are met
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
A36 is largely limited to Africa. Outside Africa, more than half of the population have no A36 and the majority that do, have only trace levels.
MFI 1550 level is usually center specific in which different transplant centers have their different cut level for desensitization to be done for the recipient. At the center, I used to work in Nigeria, our cut-off is >1000 MFI and hence I will manage as follows
References
Thank you, Isaac
Will you still give ATG even with a negative crossmatch?
Have you excluded HIVAN in the donor?
I completely disagree with desensitization in a negative crossmatch.
Thank you, prof. for your response and correction
Yes, I mentioned that I will exclude HIVAN from the donor.
· Will you accept this DBD donor?
Yes will accept if the recipient is HIV + and has;
· CD4 count is more than 200 cell/micoL.[1]
· Undetectable viral load.[1]
· On ART for at least six months
· No history of CNS Lymphoma, PML and Kaposi sarcoma.
· Patient counseling regarding integrase inhibitor- based ART regimen due to PI with effects on CYP3A4.
· Allograft function monitoring
· HIV viral Load monitoring at one month an every 3rd month.
· Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
In addition to above mentioned points in recipient, will have to exclude HIVAN or HIVIC in donor before donation, so all HIV donors must have kidney biopsy in addition to;
· must have a CD4 count of >500 cells/microL,
· and HIV viral load <20 copies/mL
· On ART for at least 6 months.
· Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
There is no consensus on the agent used for induction in HIV recipients but antibody ( rATG OR IL-2 receptor) compared to no induction has lower risk of DGF and graft loss.[2] However antibody induction didn’t reduced risk of acute rejection. Antibody therapy is not associated with increased risk of infection as well.
References
1. Stock PG, Barin B, Murphy B, et al. Outcomes of kidney transplantation in HIV-infected recipients [published correction appears in N Engl J Med. 2011 Mar 17;364(11):1082]. N Engl J Med. 2010;363(21):2004-2014. doi:10.1056/NEJMoa1001197
2. Kucirka LM, Durand CM, Bae S, et al. Induction Immunosuppression and Clinical Outcomes in Kidney Transplant Recipients Infected With Human Immunodeficiency Virus. Am J Transplant. 2016;16(8):2368-2376. doi:10.1111/ajt.13840
Thank you, Faraman
Will you still give ATG even with a negative crossmatch?
Have you excluded HIVAN in the donor?
Please go back to what we have taught you in modules 1 and 2.
Yes professor, I highlighted “all HIV donor must have kidney biopsy”
Regarding induction antibody therapy is better than no antibody so in this case I will prefer IL 2 Rather rATG
To increase the the donor pool recently and under some conditions we can accept this DBD donor.
A) HIV viral load <50 copies/mL and CD4 count >200/µL for at least 6 months prior to brain injury
b) Information about the donor virus such as historical genotype patterns where possible and current viral load
c) No history of virological failure or drug resistance
● Recipients are counselled and give informed consent both at the time of listing and at the time of transplantation
● Patients with HIV-infection are unsuitable to be living kidney donors. However, some recent trials have reported optimistic results
for example; HIV-Positive–to–HIV-Positive Kidney Transplantation — Results at 3 to 5 Years study.
performed four renal transplantations in HIV-positive recipients using kidneys from HIV-infected donors. The preliminary results from that study showed 100% graft survival and patient survival at 1 year.
the conditions that should be met
for donor
■no sepsis
■No activeTB
■ NO WHO stage 4 HIV
■ NO PROTEINURIA
■ Undetectable plasma RNA Load (less than 50 copies/ml)
For recipient
○use of antiviral treatment for more than 3months
○CD4 t cell less than 200
○undetectable plasma RNA HIV load
This type of transplantation need expertise transplantat center
In this case FCXM is neg we can accept the donor for HIV Recipient. However , we need an appropriate management
For most patients with (pos DSA) and (neg FCXM ), treatment with (IVIG) can prevent of rejection.
ATG and HIV;
●Limited studies using ATG in HIV pos recipients
●Previous guidelines recommended against.
●recently, there have been reports of successful use in HIV-positive recipients, however associated with reduced CD4 count without increased incidence of opportunistic infection, progression to AIDS or death, but may be associated with reduced graft survival.
●For the majority of HIV pos patients induction therapy is with (IL-2RA), but it may not appropriate in this case
●we should remember that Rituximab may cause leukopenia, late-onset neutropenia and decline of CD4+ and CD8+ T-cell counts.
●Antiviral treatment interacts with immunosuppression maintenance treatmen (TAC – MMF- PRED) , Therefore we should close monitoring the level of TAC and others
REFERENCES
1- Professor Halawa lecture
2 – Kidney & Pancreas Transplantation in Patients with HIV (BTS)
3-https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5090019/#__ffn_sectitle
4- https://atcmeetingabstracts.com/abstract/preexisting-donor-specific-antibody-dsa-with-a-negative-flow-crossmatch-fcxm-should-not-preclude-kidney-transplantation/
5- Preexisting Donor Specific Antibody (DSA) with a Negative Flow Crossmatch (FCXM) Should Not Preclude Kidney TransplantationV. Kumar, V. Hauptfeld-Dolejsek, A. Kamal Abdelkader, J. Goodman, J. Locke, R. Gaston
University of Alabama at Birmingham, Birmingham. Meeting 2013 American Transplant Congress
Thank you, Ghalia
Will you still give ATG even with a negative crossmatch?
Have you excluded HIVAN in the donor?
Will you accept this DBD donor?
Yes, would you accept the transplant if:
1. Sustained negative viral load (< 50 copies) in the last six months
2. No history of opportunistic diseases in the last six months
3. No history of PLE, Lymphoma or intestinal Cryptosporidium
4. Serum CD4 greater than 200 cells
5. HAART sensitivity profile, prioritizing the use of integrase inhibitors (dolutegravir) and avoiding nephrotoxic drugs (protease inhibitors and Tenofovir).
Induction with Basiliximab (IL2R blocker) is considered the best option because would be less interference with CD4 levels.
Would you accept this donor as a live donor if the recipient is also HIV positive? If yes, what are the conditions that should be met?
It is a situation that depends a lot on local criteria and ethical issues to be discussed. Both donor and recipient must be aware of this situation and a thorough study of the donor would be necessary, prioritizing the profile of resistance to HIV and the discussions that we placed in the previous topic.
If both donor and recipient have the same profile of sensitivity to antiretroviral drugs, it is possible to prioritize a scheme with Dolutegravir and avoid nephrotoxic drugs.
If the donor has a resistance scheme, either due to failure, abandonment or previous exposure, he would not proceed with the transplant. Alternative regimens for HIV control require combinations of integrase inhibitors with additional drugs to transcriptase inhibitors, decreasing their response and increasing drug interactions with other drugs, mainly immunosuppressants such as calcineurin inhibitors.
Assume the potential recipient has DSA (A36 with MFI 1550), but negative FCXM. What is your management plan?
In this case, induction should be performed with rATG, avoiding Basiliximab.
Monitoring should be very close, as it decreases CD4 lymphocyte activity and can induce AIDS and opportunistic infectious diseases. In this case, lifelong prophylaxis for Pneumocystosis is considered.
We do not have Belatacept in our service, but your indication should be considered and individualized.
Calcineurin inhibitors should be measured frequently and scheduled graft biopsies may be required to minimize the risk of graft rejection.
Thank you, Filipe
Will you still give ATG even with a negative crossmatch?
Have you excluded HIVAN in the donor?
Please go back to what we have taught you in modules 1 and 2.
Sorry, Professor. That is true.
I was worried about a deceased donor with DSA positive.
We do not have basiliximab at Brazil, so that was the motive to talk about rATG.
If the recipient is HIV positive, I will accept the donor with the following recommendation:
a) HIV viral load <50 copies/mL and CD4 count >200/μL for at least 6 months prior to brain damage b) Details regarding the donor virus, including history genotyping trends and current viral load.
b) No virological failure or drug resistance.
• Listers and transplanters are counseled and obtain informed consent
I will not accept a living donor who is HIV positive, because of the very limited data available.
HIV-to-HIV live donor transplantation has been recorded rarely. HIV-specific risk factors for ESRD, such as low CD4 cell count and HCV coinfection, must be identified in donor nephrectomy candidates.
HIV-positive African Americans with high-risk apoprotein L1 (APOL1) genotypes are at risk for HIVAN and focal segmental glomerulosclerosis, although it is unclear whether APOL1 haplotype screening is useful. HIV-positive donors should avoid nephrotoxic ART such as tenofovir and nonsteroidal anti-inflammatory drugs after nephrectomy.
Only two live donor kidney transplants have been documented, one with favorable long-term results for both donor and recipient.
Induction therapy is provided to all HIV-positive patients who are eligible for KTX. Most HIV patients induction with IL2 R
but in this case: Induction therapy is with ATG(+ve DSA)
• HIV+ individuals are given triple therapy maintenance IS (steroids, a CNI, & an anti-proliferative drug).
References:
Kumar, R. N., & Stosor, V. (2020). Organ transplantation in persons with HIV/AIDS (AIDS, 34(8), 1107–1116).
Kidney & PancreasTransplantation in Patients with HIV
Thank you, Weam
Will you still give ATG even with a negative crossmatch?
Please go back to what we have taught you in modules 1 and 2.
Please, any information on the virology results of the potential recipient?
Thank you, Isaac
This is for you to give me the options
-Until 2013 it was against federal regulation to transplant organs from someone who was HIV+ into a potential organ recipient, even if the intended organ recipient was also HIV+. However, in 2013 these HIV prohibitions were determined by Congress to be outdated. The HOPE Act directed the Health and Human Services (HHS) Secretary to develop guidelines to conduct research relating to HIV+ donors and organ transplantation to HIV+ve recipients .
-I will accept this DBD HIV+ve donor for a an HIV+ve recipient of course .
-In patients with HIV and ESKD , renal Tx has been associated with survival benefits although having a higher risk of rejection due to :
-Interaction between CNI’s and protease inhibitors(PI) may lead to subtherapeutic levels.
-rATG is feared so IL-2i are used instead which may increase the acute rejection risk .
-Patients must have an undetectable viral load and a CD4 count >200 cells/micL on a stable ART regimen for at least 6 months .
-Before the Tx , the ART regimen should be switched to a regimen that doesn’t include a protease inhibitor -(integrase inhibitors are preferred ) if possible .
-The use of induction IS with HIV remains controversial ;many centers prefer Basiliximab over rATG in HIV+ve individuals .
-If the potential recipient has DSA (A36 with MFI 1550), but negative FCXM , i will still accept this donlor , no desenstization , induction by rATG over basiliximab in this case ( but possibly lower doses) , steroids , Tacrolimus and MMF .
Refrences :
1-Up-to-date HIV and renal transplantation
2- Prof.Dr.Ahmed halawa’s lecture
Thank you, Mohamed
Will you still give ATG even with a negative crossmatch?
Have you excluded HIVAN in the donor?
Please go back to what we have taught you in module 1 and 2.
Thank you Professor ,
I will still go with rATG , our donor is a deceased one
We should do a biopsy for our donor yes to exclude HIVAN
Than you Prof.