Transplant Equity Called for Among Persons Living With HIV

In this review from University of California researchers, comparable positive outcomes for patient and graft survival were seen among persons living with HIV who underwent liver transplant, as were similar kidney graft survival rates. Patient survival rates of kidney transplant significantly differed, however.

Outcomes were compared vs controls not living with HIV who also underwent these transplants, with the authors calling for more equity in transplant access among persons living with HIV.

The findings from their retrospective, single-center, cohort, study were recently published in JAMA Surgery.

“Kidney transplant and liver transplant in HIV-positive patients have become more widely adopted,” the authors wrote. “However, data looking at long-term outcomes of patient and graft survival are lacking.”

Patient outcomes from 2000 to 2019 were observed through death or graft failure necessitating a retransplant, whichever came first, with data analyzed from 2020 to 2021.

All persons living with HIV who underwent a kidney or liver transplant were included, with data for the matching cohorts obtained from the University of California, San Francisco’s transplant recipient registry. Demographics were similar among the kidney (HIV: mean [SD] age, 51.7 [9.4] years; 72.3% men; matching controls: mean age, 52.3 [13.6] years; 68.7% men) and liver transplant (HIV: mean age, 52.6 [8.2] years; 66.3% men; matching controls: mean age, 54.6 [12.8] years; 66.1% men) groups. More persons underwent kidney (119 living with HIV; 655 controls) than liver transplant (80 living with HIV; 440 controls).

Overall, patient survival rates exceeded 50% across both HIV statuses and transplant groups at the 15-year mark after transplant:

• Kidney transplant:
  • Living with HIV: 79.6% (95% CI, 73.6%-86.1%)
  • Not living with HIV: 53.6% (95% CI, 38.9%-74.0%)
• Liver transplant:
  • Living with HIV: 60.3% (95% CI, 49.0%-74.1%)
  • Not living with HIV: 65.3% (95% CI, 54.4%-78.2%)

In addition, Cox proportional hazards regression showed that having a diagnosis of HIV was not shown to be a determining factor for worse graft survival (kidney transplant: HR, 1.09; 95% CI, 0.61-1.97; P = .77) or patient survival (liver transplant: HR, 1.36; 95% CI, 0.83-2.24; P = .22).

Graft survival rates for kidney transplant were 57.0% (95% CI, 47.8%-68.0%) among those without HIV and 75.0% (95% CI, 65.3%-86.2%) among persons living with HIV. Despite this 18–percentage point difference, the variation was deemed not significant.

For liver transplant, the patient survival rates were 60.3% (95% CI, 49.0%-74.1%) among persons living with HIV and 65.3% (95% CI, 54.4%-78.2%) among patients not living with HIV.

For the HIV cohort with at least 1 incident of acute rejection, the survival rate was 74% less compared with the persons in the group with no rejection: 52.8% (95% CI, 38.4%-72.5%; P < .001) vs 91.8%.

Additional 5-year patient survival rates were considered for persons living with HIV and comorbid hepatitis C virus (HCV), with both kidney and liver transplant recipients living with both infections having the worst survival rates prior to the advent of direct-acting antiviral (DAA) drugs in 2014. “Unfortunately, because the institution only began implementing HCV DAA in 2014, the survival analysis could only be carried out to 5 years post transplant,” the authors wrote. “Since the advent of HCV DAA, outcomes have been comparable irrespective of HCV coinfection.”

The primary outcomes of interest in this study were patient and graft survival for persons undergoing kidney transplant, the link between acute rejection and graft survival for kidney transplant, and patient survival for liver transplant.

With the acceptance of kidney transplant among persons living with HIV being high while that for liver transplant remains low, the authors believe their positive findings over such a long period do show that positive survival outcomes are possible for both transplant types among persons living with HIV—and that they indicate equity in this area of specialty care is needed but severely lacking.

“We hope that this research will continue to show the long-term safety and appropriate use of organ transplantation in HIV-positive recipients,” lead author Arya Zarinsefat, MD, said in a statement. "Hopefully transplant centers throughout the country and world will continue to advance their own programs in transplanting HIV-infected patients.”

Reference

Zarinsefat A, Gulati A, Shui A, et al. Long-term outcomes following kidney and liver transplant in recipients with HIV.JAMA Surg. Published online January 5, 2022. doi:10.1001/jamasurg.2021.6798