People who die infected with HIV represent a potential source for transplantation numbering nearly 400 annual donors in the US, to yield 192 kidneys and 247 livers for the benefit of people living with the infection, according to the estimates of researchers who say there would be knock-on benefit for noninfected patients also waiting for organs.
hospital organ transplant case
Organ supply is far outstripped by demand in the US, and those with HIV needing donation might benefit from those deceased with the infection.
The study assessed the quality of potential organs from HIV-infected deceased donors, finding for example that undiagnosed HIV-associated kidney disease would need to be assessed for future kidney donation whereas the livers were found to be of better transplant quality.
Until relatively recently, say the authors publishing their results in the American Journal of Transplantation, HIV-infected patients were considered ineligible to receive an organ transplant, but can now have survival benefit with “good renal and liver outcomes” compared with remaining on the waitlist.
In spite of this though, the US national disparity between the numbers of waiting patients and available organs “may disproportionately affect HIV-infected patients” – and these patients needing organs are more likely to die waiting than those who are HIV-negative.
America’s HIV Organ Policy Equity (HOPE) Act was signed into law in November of 2013 to allow research into organ donations from one person with HIV to another.
This study, with senior author Dr. Emily Blumberg, is the first completed since this new freedom.
A professor in infectious diseases at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Dr. Blumberg says:
“The findings are significant because there are not enough organ donors in the US to meet the needs of all of the patients who might benefit from life-saving organ transplants.”
“Some of the patients waiting for organs,” she adds, “are infected with HIV but never make it to transplant because they either die while waiting or become too sick to be transplanted.
“HIV patients who undergo transplantation generally do well, so it is important to continue to look for ways to improve access to transplantation for them.”
The risk of HIV transmission makes donation to uninfected people illegal, but these patients could still benefit from supply by HIV-infected deceased donors – simply because expanding the options for people already infected would reduce the demand on organs supplied by HIV-free donors.
About 123,000 people are currently waiting on the US list for organ transplants. But throughout almost half of last year only 11,844 people received organ transplants (January through May 2014).
The national estimates come from numbers in Philadelphia
The Penn researchers and their colleagues arrived at their estimate of potential addition to the national organ supply by reviewing the records of 578 HIV-positive patients who died at six large HIV clinics in Philadelphia, PA. This produced an assessment of their potential suitability as deceased donors.
Although research transplantation is allowed under the HOPE act, to date no known organ transplants from HIV-positive donors to HIV-positive patients have occurred in the US. Dr. Blumberg reckons the transplant waiting list for Philadelphia includes between 80 and 100 people with HIV.
From the study’s assessments of transplant numbers and viability using standard criteria for donor selection, she says:
“The two to three kidneys and three to four livers from HIV-positive donors that might be available yearly would have a small but important impact on that list [in Philadelphia].”
While offering an option versus no transplant at all, kidneys from HIV-infected donors do not meet the same high standards as those from people deceased without infection.
The study team included a fourth-year medical student in the Perelman School of Medicine. Aaron Richterman, acting as lead author, says:
“Unfortunately, the standard measurements of organ quality that we used suggest that many of the donor kidneys may be of reduced quality with decreased viability over the long term when compared with ideal donor kidneys.”
Using the kidney donor risk index, the researchers projected what the higher risk of graft failure in kidneys from the potential donors would be compared with current typical rates.
The estimated three-year graft survival rate was 70% for HIV donations compared with the 83% median average produced by kidneys transplanted in 2013.
By contrast, prospects for liver donation were better in the study’s assessment.
Against the liver donor risk index, the study projects a 71.0% chance of 3-year graft survival. This is only slightly below the 73.5% transplant success associated with organs from HIV-negative donors.
The poorer results for kidney quality may be a victim of success – Mr. Richterman explains that “the findings may reflect our greater success in treating HIV-infected individuals, who now live longer and thus are more likely to develop problems associated with poorer kidney transplant quality.”
Reduced quality of either kidneys or livers in the study also had contributing factors in the older age of potential donors, African-American race and high rates of hypertension and diabetes.
The widespread use of highly active antiretroviral therapy for HIV infection means that death has been increasingly more likely from causes other than those associated with progression to AIDS.
There has been an increasing proportion of deaths from non-AIDs cancers, cardiovascular causes, liver disease and non-AIDS infections in people infected but treated for HIV, and the authors say this trend was reflected in their study.
Written by Markus MacGill