Renal transplantation in patients with HIV/AIDS

Abstract

The human immunodeficiency virus (HIV)-infected patient is more prone to developing both acute and chronic renal failure than the general population. Renal disease specific to the HIV-infected population include HIV-associated nephropathy (HIVAN), mostly prevalent in the black population, and HIV immune complex kidney disease (HIVICK), which is more common in the white population. Some immune complex diseases of the kidney are thought, in the majority of cases, to originate from a co-infection with hepatitis C virus (HCV). As the life expectancy of this population is getting longer they are more likely to suffer from end organ damage due to age related diseases such as hypertension (HTN) and diabetes mellitus (DM). The kidney function can be monitored by estimated glomerular filtration rate (eGFR), albumin/creatinine ratio (ACR) and protein/creatinine ratio (PCR). Using ACR and PCR enables estimation of the renal function even in dilute urine and does not need sensitive lab machines, necessary for detecting tubular proteins in urine, that are not available at many hospitals. Treatment of established kidney disease is by managing modifiable factors, such as HTN, body weight and drug regimen as far as possible. Renal replacement therapy is indicated as for other patient groups with decreased renal function. If the patient fulfil certain criteria they are eligible for a renal transplant. Social stigma and lack of knowledge has led fewer HIV-infected patients to want transplantation. Among the HIV-specific criteria for transplantation include that the patient has to be well regulated with combined ART (cART) for at least six months and without a history of opportunistic infections. Immunosuppressive (IS) therapy was for a long time thought to enable the virus to freely replicate and hasten the progression to AIDS and death. Studies have later shown that by suppressing the immune system one is preventing activation of CD4+ T cells and, because the HIV-virus infect activated cells, they also protect new T-cells from being infected. IS may thus, on the contrary, even be beneficial in these patients. The drug interactions between IS and ART are many and complex and it is beneficial with multidisciplinary teams, including a infectologist and nephrologist, to choose the optimal therapy. Blood levels of the drugs should be checked with regular intervals to ensure therapeutic levels and prevent nephrotoxicity or rejection. The outcome after transplantation is continuing to improve. The frequency of rejection episodes is higher in this population, but the graft and patient survival is similar to the general population. Meta-analyses have concluded that renal transplantation should be offered to patients who fulfill the criteria, although the strength of evidence is very low due to small study samples