Kidney transplantation in HIV-positive patients: a report of 14 cases

摘要

The HAART reduces the risk of HIV-related renal disease but the incidence of end-stage renal disease (ESRD). Therefore, efficacy and safety of renal transplantation (Tx) is an important resource in the HIV-infected population. We reported the results of kidney Tx in HIV+patients from deceased donors from June 2007 to March 2012 at our institution. The patients had to have CD4+T-cell counts≥200/mm³ and undetectable plasma HIV-RNA if on HAART. The induction immunosuppressive therapy consisted of metilprednisolone and basilixmab; tacrolimus and/or mycofenolic acid were used for maintenance therapy. The therapeutic drug monitoring (TDM) has been performed for the adjusting of both their doses []. A total of 14 patients underwent kidney Tx. They were on dialysis (haemodialysis=13, 92.9%; peritoneal=1, 7.1%) for 5±3.1 years and they were included on the Tx waiting list for 10±8 months. The baseline characteristics are showed in Table 1. frame="hsides" rules="groups" class="rendered small default_table">> align="left" rowspan="1" colspan="1"> >Donor at baseline align="left" rowspan="1" colspan="1">> align="left" rowspan="1" colspan="1">Mean age align="left" rowspan="1" colspan="1">38±12.5 years> align="left" rowspan="1" colspan="1">Deceased align="left" rowspan="1" colspan="1">14/14 (100%)> align="left" rowspan="1" colspan="1">High/unclassified infectious risk align="left" rowspan="1" colspan="1">9 (64.29%)> align="left" rowspan="1" colspan="1">Recipients align="center" rowspan="1" colspan="1">> align="left" rowspan="1" colspan="1">Mean age align="left" rowspan="1" colspan="1">44 years> align="left" rowspan="1" colspan="1">Patients with previous AIDS-defining events align="left" rowspan="1" colspan="1">3 (21.4%)> align="left" rowspan="1" colspan="1">Median follow-up months (IQR range) align="left" rowspan="1" colspan="1">42.75 (8.5–55.2)> align="left" rowspan="1" colspan="1">Patient survival at last follow-up align="left" rowspan="1" colspan="1">14/14 (100%)> align="left" rowspan="1" colspan="1">Graft survival at last follow-up align="left" rowspan="1" colspan="1">13/14 (92.9%)> align="left" rowspan="1" colspan="1">Mean time of acute rejection since Tx align="left" rowspan="1" colspan="1">28±20 days> align="left" rowspan="1" colspan="1">Patients not treated with steroid at last follow-up align="left" rowspan="1" colspan="1">6 (43%)> align="left" rowspan="1" colspan="1">Plasma creatinine at last follow-up align="left" rowspan="1" colspan="1">1.87±1.93 mg/dl> align="left" rowspan="1" colspan="1">Severe infectious complications (CMV pneumonia, malaria, Kaposi sarcoma) align="left" rowspan="1" colspan="1">3 (21.4%)> align="left" rowspan="1" colspan="1">Diabetes align="left" rowspan="1" colspan="1">3 (21.4%)> align="left" rowspan="1" colspan="1">CMV infection without localization align="left" rowspan="1" colspan="1">3 (21.4%)> align="left" rowspan="1" colspan="1">Bacterial pneumonia align="left" rowspan="1" colspan="1">4 (28.6%)> align="left" rowspan="1" colspan="1">Reactivation of HIV RNA align="left" rowspan="1" colspan="1">3 (21.4%) At the last available point of follow-up (median=42.8 months, IQR=8.5–55.2), 8 out of the 13 patients (61.6%) without steroid had at least one acute rejection episode, but only 1 patient lost the graft, after 43 months (7.1%) due to chronic rejection associated with infectious and vascular complications. After Tx the median CD4+T-cell count increased from 382.5 (IQR range=233–415) to 434 (IQR range=282–605) cells/mm³ (p=0.055). In Figure 1 are reported the CD4+trends of 9 patients with a follow-up of at least 6 months.HIV infection was well controlled, with only 2 (14.3%) cases of virological failure which were promptly resolved after HAART regimen modification. Table 1 shows the observed infectious complications. The skin Kaposi sarcoma has been resolved by switching to immunosuppressive therapy with sirolimus []. Kidney Tx appears to be safe in HIV-positive patients undergoing HAART. The viro-immunological parameters remained well controlled with no increases in infectious complications or neoplasm and a satisfactory control of HIV infection. However, the high rejection rate is a serious concern and suggests to consider a steroid-containing immunosuppressive regimen also in these patients.