Kidney transplantation offers significant survival advantages to ESRD patients in the general population, but HIV was initially considered a contraindication for this solution.³Nashar K et al. World J Nephrol. 2016;5(4):300-307. However, recent studies have indicated that kidney transplantation could be safe in PWH who are well controlled on ART.³Nashar K et al. World J Nephrol. 2016;5(4):300-307. Kidney transplantation between HIV-positive donors and recipients was made possible in the United States in 2015 due to the HIV Organ Policy Equity (HOPE) Act. However, few studies have evaluated the outcomes of these transplantations. Recently, the results of a multicentre pilot study investigating the safety of kidney transplants between HIV-positive donors and recipients were published in the American Journal of Transplantation.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205

The study was a multicentre prospective pilot observational study carried out at 14 transplant centres in the United States.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 Eligible patients were HIV-positive patients aged ≥18 with ESRD, CD4 count ≥200 cells/μL within the past 16 weeks, and receiving ART with HIV RNA <500 copies/mL.[mfn referencenumber=4]Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205[/mfn] Donors could not have active opportunistic infection or cancer and had no specific criteria for HIV RNA or CD4 count, although transplant teams had to describe effective ART for the recipient.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 Screening for HIV in donors included an HIV antibody (Ab) or antigen (Ag) and HIV qualitative nucleic acid test (NAT).⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 Donors with no history of HIV but with discordant HIV Ab or NAT tests were suspected to be false positives.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205

All recipients received induction with either lymphocyte depletion or IL-2 receptor blockade with basiliximab.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 At follow-ups post-transplantation, physical examination, medications, serious adverse events (SAEs), hospitalisations, infections and laboratory values were collected.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 Quantitative HIV polymerase chain reaction (PCR) was performed at baseline and weeks 1, 2, 3, 4, 13, 26, and every 6 months thereafter, while CD4+ T-cells were measured at baseline and weeks 4, 8, 13, 26, and every 6 months thereafter.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 Biopsies were collected at baseline, and every 3 months, and one-year post-transplant in the HIV donor positive arm until April 18, 2017, at which point the biopsies were collected every 6 months instead of 3.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 Rejection was defined as clinically-suspected and treated rejection or biopsy-proven rejection according to Banff classification.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205

Kidney transplants were performed in 75 patients in this pilot study, of which 25 were HIV donor- and recipient-positive transplants (D+/R+), and 50 were HIV donor-negative and recipient-positive transplants (D-/R+).⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 The median recipient age was 51 years, 29% were female, and 23% were co-infected with hepatitis C virus (HCV).⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 The most common cause of renal disease was hypertension, followed by HIV-associated renal disease.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 At transplant, 91% of recipients were receiving an integrase strand transfer inhibitor (INSTI)-containing ART, 27% on non-nucleoside reverse transcriptase inhibitors (NNRTIs), and 8% on boosted protease inhibitors with cobicistat.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205

Patient survival was 100% in both D+ and D- patients, with a median follow-up of 1.4 years and 1.8 years, respectively.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 Delayed graft function occurred in 12% of D+ and 42% of D- recipients (p=0.01), and there were more graft failures in D- recipients than D+ patients (5 vs 2).⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 One-year graft survival rates were similar between D+ and D- recipients (91% vs 92%), and the risk of graft failure was similar (HR=0.90; 95% CI: 0.17-4.66; p=0.90).⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 One-year graft function was also similar between both groups, with no statistical difference regarding the trend for renal function.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205

Rejection occurred in 44% of D+ and 32% of D- recipients (p=0.56). Most patients (81%) had one episode, but 2 D+ and 3 D- recipients had 2 episodes.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 Induction with basiliximab was strongly associated with one-year rejection compared with lymphocyte depletion (44% vs 21%; HR=0.33; 95% CI: 0.12-0.87; p=0.03).⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 There were no differences in SAE or infections between D+ and D- recipients, and HIV breakthrough was rare (4% D+ vs 6% D-; p>0.99). In the 4 cases of HIV breakthrough, ART was interrupted due to insurance lapses, and viral load was re-suppressed upon re-initiation of ART.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205 No post-transplant malignancies were observed in D+ recipients, but three malignancies, Kaposi sarcoma, oropharyngeal carcinoma, and gastric adenocarcinoma, developed in D- recipients.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205

The results of this pilot study demonstrate comparable overall patient and graft survival between HIV-positive and -negative donors to HIV-positive recipients, with no evidence of increased SAEs or HIV-related complications.⁴Durand CM et al. Am J Transplant. doi: 10.1111/ajt.16205