Kidney and liver organ transplantation in persons with human immunodeficiency virus: An evidence-based analysis

The objective of this analysis is to determine the effectiveness of solid organ transplantation in persons with end stage organ failure (ESOF) and human immunodeficiency virus (HIV+) Clinical Need: Condition and Target Population: Patients with end stage organ failure who have been unresponsive to other forms of treatment eventually require solid organ transplantation. Similar to persons who are HIV negative (HIV-), persons living with HIV infection (HIV+) are at risk for ESOF from viral (e.g. hepatitis B and C) and non-viral aetiologies (e.g. coronary artery disease, diabetes, hepatocellular carcinoma). Additionally, HIV+ persons also incur risks of ESOF from HIV-associated nephropathy (HIVAN), accelerated liver damage from hepatitis C virus (HCV+), with which an estimated 30% of HIV positive (HIV+) persons are co-infected, and coronary artery disease secondary to antiretroviral therapy. Concerns that the need for post transplant immunosuppression and/or the interaction of immunosuppressive drugs with antiretroviral agents may accelerate the progression of HIV disease, as well as the risk of opportunistic infections post transplantation, have led to uncertainty regarding the overall benefit of transplantation among HIV+ patients. Moreover, the scarcity of donor organs and their use in a population where the clinical benefit of transplantation is uncertain has limited the availability of organ transplantation to persons living with ESOF and HIV. With the development of highly active anti retroviral therapy (HAART), which has been available in Canada since 1997, there has been improved survival and health-related quality of life for persons living with HIV. HAART can suppress HIV replication, enhance immune function, and slow disease progression. HAART managed persons can now be expected to live longer than those in the pre-HAART era and as a result many will now experience ESOF well before they experience life-threatening conditions related to HIV infection. Given their improved prognosis and the burden of illness they may experience from ESOF, the benefit of solid organ transplantation for HIV+ patients needs to be reassessed. Evidence-Based Analysis Methods: Research Questions What are the effectiveness and cost effectiveness of solid organ transplantation in HIV+ persons with ESOF? Literature Search A literature search was performed on September 22, 2009 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) for studies published from January 1, 1996 to September 22, 2009. Inclusion Criteria [black square] Systematic review with or without a Meta analysis, RCT, Non-RCT with controls [black square] HIV+ population undergoing solid organ transplantation [black square] HIV+ population managed with HAART therapy [black square] Controls include persons undergoing solid organ transplantation who are i) HIV- ii) HCV+ mono-infected, and iii) HIV+ persons with ESOF not transplanted. [black square] Studies that completed and reported results of a Kaplan-Meier Survival Curve analysis. [black square] Studies with a minimum (mean or medium) follow up of 1-year. [black square] English language citations Exclusion Criteria [black square] Case reports and case series were excluded form this review. Outcomes of Interest i) Risk of Death after transplantation ii) Death censored graft survival (DCGS) iii) HIV disease progression defined as the post transplant incidence of: – opportunistic infections or neoplasms, – CD4+ T-cell count < 200mm3, and - any detectable level of plasma HIV viral load. iv) Acute graft rejection, v) Return to dialysis, vi) Recurrence of HCV infection Summary of Findings: No direct evidence comparing an HIV+ cohort undergoing transplantation with the same not undergoing transplantation (wait list) was found in the literature search. The results of this review are reported for the following comparison cohorts undergoing tran

• Population(s)
  • General HIV+ population
• Co-infections
  • Hepatitis B, C
• Co-morbidities
  • Other