In a first that gives HIV-positive patients yet another chance for long lives, surgeons at Johns Hopkins University Medical Center have transplanted a kidney and a liver from a deceased donor who was positive for HIV into two HIV-positive recipients.
The groundbreaking transplant surgeries using organs from an HIV-positive donor ends a 25-year stretch during which the organs of HIV-positive people willing to donate them were rejected for use in transplants. The experimental procedure follows the 2013 enactment of the HIV Organ Policy Equity (HOPE) Act, which repealed the ban on using such organs for transplantation.
“This is an unbelievably exciting day for our hospital and our team, but more importantly for patients living with both HIV and end-stage organ disease,” said Dr. Dorry L. Segev, the Johns Hopkins surgeon who performed the surgeries. “For these individuals, this could mean a new chance at life.”
The liver transplant was the world’s first involving an HIV-positive donor and recipient, and the kidney transplant was the first such surgery in the U.S., according to the medical center.
“What we had done before was take HIV-negative organs and put them into HIV-positive people,” Segev said. “Using an HIV-positive organ adds one degree of complexity, which is now there’s a new strain of HIV being introduced into the recipient. The thing we have to do is just make sure that their HIV regimen gets adapted accordingly.”
Segev, professor of surgery at the Johns Hopkins University School of Medicine, played a key role in lobbying Congress to change the longstanding ban on the use of HIV-infected organs in transplantation.
Under the new law, only transplant recipients who are HIV-positive will be eligible to receive organs from HIV-positive donors. Still, the change is expected to make hundreds and potentially thousands of transplantable organs available each year to HIV-infected people with end-stage diseases of the kidneys, heart, liver or lungs.
While the surgeries at Hopkins involved the use of organs from a deceased donor, experts expect that in the future, some living HIV-positive donors will step forward to offer a kidney for transplantation.
As other transplant centers join Hopkins in performing the procedures, the practice promises to shorten the line for all who await the call that a donor organ has become available.
There are 121,220 patients listed on the Organ Procurement and Transplantation Network’s waiting list, and another name is added, on average, every 10 minutes. Each day, an average of 22 patients die waiting for an organ.
Of the close to 31,000 organ transplants performed annually in the United States, those involving organs from HIV-infected donors will remain a small minority: Experts estimate that each year, 500 to 600 HIV-positive people would die under circumstances that would make their organs available for transplant. As more HIV-infected patients on the waiting list receive organs, uninfected patients will also move up in line.
Dr. David Klassen, chief medical officer of the United Network for Organ Sharing, said that key questions remain about the new generation of transplants, which are conducted under rules that treat them as research procedures. Among those are whether organs from HIV-positive donors will be as resilient as organs that have come from uninfected donors.
Klassen also said that in matching donors and recipients, physicians will have the added challenge of trying to ensure that an HIV-infected recipient does not get an organ from a donor infected with a more aggressive strain of the human immunodeficiency virus. In most cases, he said, that fit can be assumed if both recipient and donor have taken the same anti-viral medications and done well on them.
But in cases in which a deceased donor’s HIV infection is diagnosed at the time of his or her death, that may not be possible, said Klassen.
Still, Klassen emphasized that the new procedures underscore how dramatically the prognosis for HIV-positive patients has changed.
“Certainly for years when HIV first came on the scene, it was a fatal illness: Everybody that got it died,” he said. HIV-positive patients were not likely to get listed on the wait list because their prognoses were poor, and the thought of using HIV-infected organs would have been unthinkable, he said. With the success of anti-viral cocktails in treating HIV-infected people, “patients really have good prospects for long-term survival,” Klassen said.
“All these changes in transplantation are completely dependent” on those changes, he said. HIV-positive patients, who are higher risk of developing kidney failure because of the disease, have long been eligible to stand in line for transplanted organs alongside uninfected patients.
And at major transplantation centers, surgeons have substantial experience in performing surgeries on HIV-infected patients. Between 2005 and 2015, surgeons in the United States have transplanted donated organs into 1,376 HIV-positive patients, and centers where those procedures have been performed will be the first to gain approval for transferring organs from HIV-positive donors to HIV-positive recipients.
Those surgeries have helped physicians work out the medication regimens and other treatment issues that work best for HIV-positive transplant patients.
The two transplant recipients at Hopkins will receive the same follow-up care as patients who do not have HIV, Segev said.
“This is going to be the same as any other liver and kidney transplant,” he said. “We’ll see them very frequently initially, and that frequency will decrease as they improve and as things get more stable.”
While Hopkins is the first transplant center to perform the experimental procedure in the U.S., two others — Hahnemann University Hospital in Philadelphia and Mount Sinai Medical Center in New York — have also applied to perform such procedures as donor organs become available.
As of late Tuesday, five HIV-positive transplant candidates were listed at approved centers for HIV-positive organs, according to UNOS spokeswoman Anne Plaschke. Four were awaiting a kidney and one awaits a donated liver, she said.
©2016 Los Angeles Times