Kidney transplantation

HIV-positive patients who are in need of a new kidney have delayed referral to  kidney transplantation programs; and spend more time on the wait list, according to preliminary data from two independent studies present at the American Transplant Congress in Boston. One study found high rates of inadequate viral suppression and psychiatric disease; but commodities in the other study did not explain away the difference in time on the waiting list.

Aware of this disparity

“It is possible that patients who have HIV and are on dialysis are not receiving transplant referrals at the same rate; and that this is affecting their decreased access to the wait list. If this is the case, then providers should be aware of this disparity and work even harder to provide adequate education about transplantation; and timely referrals for these patients,” Ashton A. Shaffer, an MD-PhD candidate at Johns Hopkins University School of Medicine in Baltimore and co-author of one of the studies, told Reuters Health by email.

However, Shaffer and colleagues studied a multi center cohort of 98 HIV-positive patients; and 3105 other patients with end-stage renal disease from 2008-2017. The median time from evaluation to wait listing was 315 days for the HIV patients; and 133 days for the others (log rank P<0.01). HIV patients were slightly younger, 91 % black (versus 43 percent of the other group) and more likely to have cognitive impairment (15 % versus 6 %). Adjusting for those factors, HIV patients were less likely to be listed (adjusted hazard ratio: 0.70, 95%CI: 0.52-0.93; “<0.05).

HIV patients spent a median of 2.4 years on dialysis before evaluation for kidney transplantation, compared to 1.3 years for other patients. Adjusting for this difference appeared to explain some of the disparity in wait list delays (aHR: 0.90, 95%CI: 0.67-1.20; P=0.5). Shaffer emphasize the preliminary nature of the data; and she and her team are working now to validate their findings.

“We are still working to understand precisely why it takes longer for patients with HIV to be added to the wait list; but (we) don’t believe that it is related to their post-transplant survival,” Shaffer said. “Prior work from our lab and others has shown that candidates with HIV; have similar survival post-transplant as otherwise similar HIV-(negative) counterparts.”

Kidney transplantation wait lists

But in a separate study of barriers to kidney transplant facing HIV patients; Dr. Suzanne Boyle at Drexel University College of Medicine in Philadelphia and colleagues reviewed data on 61 patients; at a primary care HIV clinic who were eligible for kidney transplantation wait lists from 2008-2015. However the patients’ demographic and health profiles were broadly similar to the HIV patients in Dr. Shaffer’s study, with two notable differences. The majority did not have adequate viral suppression; and there was also a high rate of psychiatric disease, at 52 percent. But both findings may be targets for reducing wait list delays, Dr. Boyle and colleagues wrote in their presentation.

“While the last 20 years have demonstrated that HIV-positive kidney transplant recipients enjoy outcomes that are similar to HIV-negative recipients; they are a very select group of individuals. There are many more patients with advance kidney disease living with HIV that face barriers to receiving a kidney transplant evaluation; or attaining active waitlisting status. Work needs to be done to help these patients address their barriers,” Dr. Boyle told Reuters Health by email

“Historically, individuals with HIV have faced great stigma. We’re trying to educate health care providers, and there are factors (that explain) why we’re seeing these barriers. One of them may be that in the beginning of the epidemic, patients didn’t have access to effective antiretroviral therapy. Now, access to safer, better tolerated antiretrovirals with fewer drug interactions have improved clinical outcomes following transplant,” Dr. Zangeneh told Reuters Health. In short, HIV care has changed and patients with chronic renal disease should receive transplantation early to achieve the best outcomes,to lead a good life and appropriate support to help them navigate the system, Dr. Zangeneh said.