/ 30 October 2008

SA pioneers HIV+ transplant

New procedure throws lifeline to HIV-positive renal patients.

Two HIV-positive South Africans have received transplanted HIV-infected kidneys — the first time in the world that a ‘positive-to-positive” transplant has occurred.

The operations were performed in September at Cape Town’s Groote Schuur hospital by specialist surgeon Dr Elmi Muller. The two male recipient patients each received a kidney from a single donor. The patients declined to be identified but Muller says the operations have been highly successful, with both patients discharged from hospital and doing well.

International studies have shown that people living with HIV who receive HIV-negative transplants do as well in the longer term as uninfected transplant recipients do.

It appears paradoxical that patients who have an immuno­suppressive illnesss — HIV — can have transplants that require the lifelong use of immunosuppressive drugs. The key is successful anti­retroviral therapy. Francois Venter, of the Southern African HIV Clinicians Society, says: ‘The antiretrovirals are so potent that they essentially remove HIV from the equation, then we can focus exclusively on the transplant immunosuppression.”

In South Africa, as in much of the world, there is a huge shortage of donor organs. In Johannesburg nephrologists and surgeons are also preparing to carry out ‘positive-to-positive” transplants. Charlotte Maxeke hospital has just 55 dialysis slots and patients wait an average of four years for a kidney from a dead donor — if they survive that long. Consultant nephrologist Dr June Fabian says that while giving HIV-negative organs would be the best option for her HIV-positive patients, up to 75% of such patients would accept an HIV-positive kidney.

A study in Johannesburg last year found that about 30% of all organ donors were HIV-positive and, as a result, their organs were simply thrown away.

Offering HIV-positive individuals the chance to take one of these organs increases the odds of finding a donor. The benefits would spread to all patients with renal dysfunction: increasing the pool of potential donors for HIV-positive individuals would increase the number of transplants being performed and free up dialysis slots for other patients. After the first year a kidney transplant is much more cost-effective than dialysis and dramatically improves quality of life.

Both Cape Town patients chose to go ahead with the procedure despite knowing they would become infected with a new strain of HIV from the donated organs. The two patients also knew there was a possibility the organs might have been damaged by the donor’s own HIV disease and so could be less durable.

Another fear in giving HIV-positive transplants is that if the donor had drug resistant strains of the virus the recipient would develop drug resistance too. Muller says that fortunately the levels of antiretroviral resistance in South Africa are relatively low.

Her two Cape Town patients counted these risks worth taking given the alternative: a life subjugated to dialysis machines, or a premature death. Each patient had been paying about R2 000 a week for dialysis.

Until recently HIV-positive people in South Africa were not eligible for organ transplants, which also prevented them from getting on to the dialysis waiting list. Fabian says that even now, with the policy changed, people living with HIV are discriminated against when it comes to getting a dialysis slot or transplant organ.

Muller says the ideal is to transplant a negative kidney into both positive and negative patients, but in cases where such organs are not available HIV-positive organ transplants appear to provide an ethical and lifesaving alternative.

Muller’s groundbreaking operations offer researchers the opportunity to improve their knowledge of HIV and its interactions with the immune system. For the first time researchers will be able to monitor from the beginning what happens when a person becomes infected with a second strain of HIV. This will have implications for all aspects of research into HIV prevention and treatment.

Fabian has several HIV-positive patients waiting for renal transplants. Thirty-two-year-old Phileas* has known since 1995 that he is HIV-positive and suffered kidney failure this year. He has a small son, and his family is struggling financially. He would consider an HIV-positive transplant if nothing else was available. ‘It would be like being born again,” said Phileas.

* Not his real name