Organ transplants for patients with HIV on the rise

Organ transplants for patients with HIV on the rise

By DAVID WAHLBERG dwahlberg@madison.com 608-252-6125 | Posted: Wednesday, October 7, 2009 12:30 pm

Tony Cunning, infected with HIV for at least 20 years, has lived long enough to encounter another serious medical problem: kidney failure.

Now the 48-year-old Milwaukee man is showing how much many doctors consider HIV, the AIDS virus, a chronic disease and no longer a death sentence.

He received a kidney transplant last month at University of Wisconsin Hospital, becoming one of the state's first HIV-positive patients to get a life-saving resource once thought too scarce for them.

"I was a sick puppy," Cunning said last week while recovering at the hospital, where the transplant made him excited about his future. "The adrenaline has me going."

A nationwide organ donor shortage remains, and more than 6,000 people die while waiting for transplants each year. But antiviral HIV medications, first available in the mid-1990s, are keeping many patients alive for decades.

The average life expectancy after an HIV diagnosis was 23 years in 2005, up from 11 years in 1996, according to a study in September by the Centers for Disease Control and Prevention. Patients who manage their infections well with drugs are expected to live considerably longer, and doctors say they are as deserving of transplants as anyone else.

The immune-suppression drugs that transplant recipients must take to prevent organ rejection were initially considered too risky for patients with HIV because the virus compromises their immune systems. But researchers have found that the drugs don't make well-managed HIV infections any worse.

"Patients with HIV who meet the transplant criteria should be considered for transplant," said Dr. Tony D'Alessandro, liver transplant director at UW Hospital. "The HIV stigma should be melting away."

Study results mixed

UW Hospital performed a liver transplant on another patient with HIV last month. Froedtert Hospital did the state's first transplant on an HIV-positive patient last December; that person received a kidney.

Wisconsin has had just the three cases. Nationwide, more than 500 transplants have been done in patients known to have HIV since 1989, according to the United Network for Organ Sharing, which oversees the country's transplant system. The HIV status of about 13 percent of transplant patients isn't publicly known.

The vast majority of the procedures in patients with HIV have been within the past five years. Almost all involve kidneys and livers. Four hearts, one lung and one pancreas have been placed in HIV-positive patients, according to UNOS.

"We transplant kidneys into people in their 70s with Type 2 diabetes, so why not patients with HIV?" asked Dr. Peter Stock, of the University of California-San Francisco.

Stock heads up the main study of HIV-positive transplant recipients, sponsored by the National Institutes of Health. Up to 275 patients with HIV are undergoing transplants at 20 medical centers around the country and being followed for five years.

Early results show that 94 percent of the HIV-positive kidney recipients were alive three years after their transplants, and the kidneys were still functioning in 83 percent of recipients (some had to go back on dialysis). The figures mirror the outcomes for patients without HIV, Stock said.

Despite having faulty immune systems, the HIV-positive kidney recipients have had more rejection problems with their organs than those without HIV. "It's not the absence of an immune system; it's the presence of a very disregulated immune system," Stock explained.

HIV-positive liver recipients haven't fared as well as their HIV-negative counterparts, especially those whose liver disease is caused by infection with hepatitis C. Those with hepatitis B, another liver infection, are doing as well, Stock said.

HIV status doesn't affect where a patient is placed on the organ waiting list. To shorten the wait, many patients in the study have agreed to receive "marginal" donor organs - those from high-risk donors, which are frequently turned down by hospitals, doctors or patients, Stock said.

All study patients must be on antiviral HIV drugs, have an undetectable level of HIV and harbor a substantial reserve of immune-boosting T-cells.

Fighting for life

The same requirements apply at UW Hospital, which isn't part of the study, D'Alessandro said.

He said the surgery teams conducting the transplants in Madison took the same "universal precautions" they take during any surgery, such as wearing gloves, washing hands and handling sharp instruments carefully.

The liver transplant patient, who has hepatitis B and has not been identified, is doing well, D'Alessandro said.

Cunning, the kidney recipient, has experienced "delayed graft function," which affects about a quarter of kidney recipients, D'Alessandro said. He has to continue dialysis while waiting for his transplanted kidney to function, a problem that is usually resolved after about two weeks, D'Alessandro said.

Cunning must now follow strict regimens of anti-rejection drugs and antiviral HIV drugs. But he said he is grateful for the transplant after eight years of dialysis.

He contracted HIV, he said, by having unprotected sex with multiple partners, a risk fueled by drug and alcohol use. He suspected he had HIV for a while but delayed testing because of the stigma.

Cunning, a father of two, said he hopes the transplant will allow him to see more of his three grandchildren's football games and other activities.

He's determined to do well, despite the early problem with his transplanted kidney.

"It's going to be a fight," he said. "But there's nothing about this HIV for the last 20 years that hasn't been a challenge."

TRANSPLANTS BY THE NUMBERS

Patients on the national organ waiting list: 104,065

Patients on Wisconsin's waiting list: about 1,600

Transplants last year in U.S.: 27,964

Transplants last year in Wisconsin: 734

Patients who died waiting for transplants last year in U.S.: 6,640

Patients who died waiting last year in Wisconsin: 99

Patients with HIV who have received transplants in U.S. (through June 30 this year): 506

Patients with HIV who have had transplants in Wisconsin: 3

Sources: United Network for Organ Sharing, Donate Life Wisconsin