Similar survival rates found in people who get dual organ transplants — regardless of HIV status

Thanks to HIV treatment (antiretroviral therapy; ART), many people with HIV are living longer, healthier lives. The benefits of ART are so tremendous that many ART users are living well into their senior years.

Although ART can significantly suppress levels of HIV and largely help repair the immune system, it does not resolve every issue caused by HIV infection. For instance, increased inflammation and immune activation persist, despite good adherence to ART.

Researchers who study inflammation suggest that this issue likely contributes to many health conditions, including the following:

• cardiovascular disease
• cancer
• type 2 diabetes
• depression
• degenerative conditions of the brain
• fat accumulation in the liver
• thinning of bones (osteopenia and osteoporosis)
• loss of muscle tissue
• premature aging of the immune system
• high levels of cholesterol

It is likely that excess inflammation and immune activation over the long term contribute to similar issues in people with HIV.

The precise cause of excess inflammation and immune activation in people with HIV despite the use of ART is not clear. However, some research suggests that early in the course of HIV infection the virus causes events that injure the lining of the gut and deplete cells of the immune system in the intestine. ART does not fully reverse these issues. Furthermore, bacteria and fungi in the intestine can leak proteins across the gut that then enter the blood. These microbial proteins stimulate the immune system and help keep it activated and inflamed.

As people with HIV age, they are prone to complications and comorbidities like people without HIV. Some of these health issues are listed above. It is possible that over time a vital organ can become degraded in its ability to function. In such cases, an organ transplant may become necessary.

Review of organ transplants in the U.S.

Prior to the availability of ART, organ transplantation was discouraged for people with HIV. However, the transplantation of organs has increased among people with HIV in the ART era. Little is known about the transplantation of multiple organs in people with HIV. To remedy this, a team of researchers at Columbia University in New York reviewed detailed information from a transplant registry (United Network for Organ Sharing). They focused on the years between 2010 and 2023 and captured information from 70 transplant centres across the U.S. The researchers focused primarily on survival rates after transplantation.

Results

As heart transplants are common in the transplant field, the researchers examined rates of this organ transplantation. They found that 175 people with HIV underwent a heart transplant, of which 26 people (15%) received an additional transplanted organ. During the study, about 10% of 4,251 people who received a heart transplant (the vast majority of whom were HIV negative) also received a transplant of another organ. So, it appeared that people with HIV were more likely to receive transplants of two (and sometimes more) organs.

Heart transplantation was the most common organ transplanted among people with HIV. Trends in dual transplants among people with HIV were as follows:

• heart + kidney
• heart + lung
• heart + liver

On average, most people with HIV who received one or more transplanted organs were in their 50s and were assigned male at birth (69%); 31% were assigned female at birth. About half of the people with HIV were Black.

The most common reasons for the heart transplant were as follows:

• enlarged and stretched chambers of the heart (dilated cardiomyopathy) – this makes it difficult for the heart to pump blood to the rest of the body
• a weakened heart arising from a reduced supply of oxygen-rich blood to this organ (ischemic cardiomyopathy)

All transplanted organs were from people who were HIV negative.

Researchers provided analyses for one to two years following transplantation.

Survival

Among people with HIV who received a heart transplant, the survival rate one year later was 88%. Among HIV-positive people who received a heart transplant and another organ transplant, the survival rate after one year was 83%. Survival rates were not significantly different among people without HIV.

Focus on the kidney

Eleven people with HIV who received a kidney transplant underwent dialysis (filtering of the blood to remove waste products) because the transplanted kidney did not work well, at least initially. After one year, only two of these people still required dialysis. Nine of the 11 people who received a kidney transplant also had a heart transplant.

Researchers found that people with HIV who received a kidney and another organ transplant were more likely to develop severe kidney injury in the transplanted kidney compared to people without HIV who also received two organs, including a kidney. The reasons for this difference are not known.

Cancer risk

Transplant drugs suppress the immune system. This immune suppression from medicines is necessary to ensure that the transplanted organ survives. Without the use of transplant drugs, the recipient’s immune system would attack and destroy the transplanted organ because it senses the organ as foreign.

Doctors working in the transplant field try to find a balance between immune suppression from the transplant drugs and the health of the transplanted organ and person who received it. Despite this search for balance, in general, people who receive transplanted organs (regardless of HIV status) are at heightened risk for cancer. HIV itself is associated with an increased risk of certain cancers.

In the present study, the risk of cancer was similar among people with transplanted organs regardless of HIV status.

Among people with HIV, some cancers that developed were as follows:

• Kaposi’s sarcoma of the skin or internal organs
• colorectal cancer
• basal or squamous cell cancer

Rejection

As mentioned earlier, the immune system of a person who receives a transplanted organ can reject that organ because it is foreign tissue. This is why some degree of immune suppression with transplant drugs is necessary.

The researchers reported relatively low rates of rejection in people with HIV who received a heart transplant and in those who received a dual transplant.

After hospitalization, people who received dual organs were prescribed regimens consisting of standard transplant medicines (one or more of tacrolimus, mycophenolate mofetil/mycophenolic acid, prednisone).

Room for improvement

The number of people with HIV who have received one or more transplanted organs is increasing. Furthermore, survival figures in the study are positive. The researchers stated: “…our findings suggest that dual organ transplantation can be safely performed and should be expanded to those [people with HIV who need it].” However, longer monitoring of more people with HIV who have transplanted organs is required.

These findings are encouraging, as in the past people with HIV had no or limited access to transplantation. However, the research team found that the overall number of people with HIV who have received organ transplants “remains small, despite high rates of both cardiovascular disease and chronic kidney disease in this population.”

The researchers noted that Black patients “continue to have a lower likelihood of transplantation and higher post-transplant mortality compared to White patients.” They added that “careful attention must be made to avoid bias in referrals to [transplant centres], waitlist care and post-transplant management.”

By Sean R. Hosein

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