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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 12  |  Issue : 1  |  Page : 64-66

ABO-Incompatible living donor kidney transplant in a human immunodeficiency virus-positive woman


Department of Nphrology, Institute of Renal Sciences, Global Hospital, Mumbai, Maharashtra, India

Date of Web Publication29-Mar-2018

Correspondence Address:
Dr. Bharat V Shah
Institute of Renal Sciences, Global Hospital, Parel, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_59_17

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  Abstract 


With recent advances in the treatment of human immunodeficiency virus (HIV), renal transplantation is no longer considered a contraindication in properly selected HIV-positive patients. However, while doing transplant in an HIV-positive patient, one needs to keep in mind the interaction between HIV drugs and immunosuppressive drugs. Further, doing an ABO-incompatible (ABOi) transplant could be a challenge due to higher immunosuppression that can result from the desensitization, exacerbating HIV-related immune dysfunction. We report a case of successful living-related donor ABOi kidney transplant in an HIV-positive patient.

Keywords: ABO-incompatible living donor kidney transplant, human immunodeficiency virus positive, plasmapheresis


How to cite this article:
Virani ZA, Rajput P, Nandu VP, Shah BV. ABO-Incompatible living donor kidney transplant in a human immunodeficiency virus-positive woman. Indian J Transplant 2018;12:64-6

How to cite this URL:
Virani ZA, Rajput P, Nandu VP, Shah BV. ABO-Incompatible living donor kidney transplant in a human immunodeficiency virus-positive woman. Indian J Transplant [serial online] 2018 [cited 2019 Sep 22];12:64-6. Available from: http://www.ijtonline.in/text.asp?2018/12/1/64/228927




  Introduction Top


Kidney transplantation is the treatment of choice in most patients with kidney failure. For human immunodeficiency virus (HIV) positivity, this was considered an absolute contraindication because of the concern that immunosuppressive drugs would lead to further immunocompromised state and higher risk of infection and malignancy. With advances in the treatment of HIV, renal transplantation is no longer considered a contraindication in HIV-positive patients with no history of opportunistic infections, CD4 count >200/μL, and undetectable viral load. Opportunistic infections which remain a contraindication for solid organ transplantation in general include chronic cryptosporidiosis, progressive multifocal leukoencephalopathy, and systemic Kaposi's sarcoma. Several studies suggest that patient and graft outcomes are like those reported for patients without HIV. All these studies mention about ABO-compatible (ABOc) kidney transplant. To our knowledge, there is only one report in the world and none from India of ABO-incompatible (ABOi) living-related donor transplant in an HIV-positive patient. Here, we report a case where immunosuppressive protocol was modified in view of HIV positivity and HIV drugs were modified to avoid interaction with immunosuppressive drugs.


  Case Report Top


A 27-year-old HIV-positive female was found to have hypertension, proteinuria, and elevated creatinine in 2014. A native kidney biopsy was done which was reported as focal segmental glomerulosclerosis. She rapidly progressed to end-stage renal disease in the next 2 years. She initiated hemodialysis through a right internal jugular vein-tunneled cuffed catheter, but after 2 months switched on to continuous ambulatory peritoneal dialysis (CAPD). She was not comfortable with CAPD and hence presented to us for kidney transplant.

On evaluation, she was found to be suitable for transplant. The CD4 cell count was 267/μL and HIV viral load was <20 copies. She was receiving raltegravir 400 mg twice a day, abacavir 300 mg twice a day, and lamivudine 50 mg once a day for her HIV positivity.

The only available donor from the family was her 53-year-old father who on medical evaluation was suitable but whose blood group was B+ (recipient A+). A swap transplant was suggested. However, since the medicolegal formalities required for a swap transplant would have taken long time,[1] the family requested an ABOi transplant.

Her anti-B IgG and IgM titers were 1:64. Our standard desensitization protocol for ABOi transplant includes rituximab 200 mg on day - 7 and day 0 and plasmapheresis and/or immunoadsorption to achieve antiblood group antibody titers <1:16.[2] This was modified in her case. She was given only single dose of rituximab 200 mg on day - 7 to minimize the risk of intense immunosuppression. She received one session of plasmapheresis and after this her anti-B IgG and IgM titers were 1:8 preoperatively.

She underwent an ABOi living donor kidney transplant on July 26, 2016. She was given no induction treatment because of her HIV positivity. Further, in the Indian setting, basiliximab has not been shown to improve outcome even in poorly matched (defined as less than haplo match) ABOc living-related donor transplants.[3] Her maintenance immunosuppression included tapering doses of steroids, mycophenolate sodium, and tacrolimus. The target tacrolimus level was between 5 and 10 ng/ml. She had an uneventful posttransplant course and she was discharged with a serum creatinine of 0.78 mg%. On discharge, she was also started on valganciclovir and cotrimoxazole prophylaxis. Her highly active antiretroviral therapy included lamivudine (100 mg/day), abacavir (600 mg/day), and raltegravir (800 mg/day) which do not interact with mycophenolate mofetil or tacrolimus.

A few days after discharge, she developed diarrhea for which mycophenolate was changed to azathioprine (2 mg/kg once a day) which also does not interact with the HIV drugs she was on. A month after transplant, she developed leukopenia and her azathioprine was stopped.

She is now >12 months posttransplant with stable graft function. She is on dual immunosuppression (tacrolimus and prednisolone) and lamivudine 100 mg, abacavir 600 mg, and raltegravir 800 mg/day for her HIV positivity.


  Discussion Top


HIV infection was once considered a contraindication to renal transplantation due to the potential risks of chronic immunosuppression exacerbating HIV-related immune dysfunction. However, advances in antiretroviral therapy led to pilot trials of kidney transplantation in HIV-positive individuals and that demonstrated acceptable results. The growing literature indicates that HIV-infected patients can be transplanted safely and enjoy posttransplant outcomes comparable to their uninfected counterparts.

A comprehensive review and meta-analysis of 12 series by Luis Landin concluded that kidney transplantation appears to be safe in patients undergoing HAART.[4] There are, however, a few problems in these cases. The risk of acute rejection is higher.[5],[6] The higher rates of rejection could be due to the interaction with some antiretroviral drugs. For example, nonnucleoside reverse transcriptase inhibitor administration may result in subtherapeutic levels of immunosuppressive drugs. Gruber et al.[7] however did not observe higher rejection rates. There can also be a problem of nephrotoxicity. Protease inhibitors may lead to toxic supratherapeutic levels of calcineurin inhibitors and mammalian target of rapamycin inhibitors.[8] Finally, HIV infection of the allograft may also contribute to allograft loss.[9]

Like HIV positivity, ABO incompatibility was also at one time considered an absolute contraindication for kidney transplant. With desensitization methods achieving adequate anti-blood group antibody reduction before transplant, results of ABOi transplant are now comparable to those of ABOc kidney transplants.[10] An Indian study by Jha et al.[11] also showed that graft and patient survival was at par with ABOc ones.

The main concern about performing ABOi kidney transplant in an HIV-positive patient is that aggressive preoperative immunosuppression for desensitization can exacerbate HIV-related immune dysfunction and increase the risk of infection. Campara et al.[12] were the first to report ABOi renal transplantation in a 47-year-old African-American man with HIV positivity. They used standard protocol (interleukin-2 receptor antagonist induction along with tacrolimus and mycophenolate mofetil maintenance) after desensitization to reduce antiblood group antibody titers before transplant. We modified our protocol to reduce the risk of severe immunosuppression. We used only one dose of rituximab 200 mg on day 7 (instead of two doses) as part of desensitization protocol and we used no induction agent.

To our knowledge, this is only the second report in the world and first in India of ABOi kidney transplant in an HIV-positive patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
2.
Shah BV, Rajput P, Virani ZA, Warghade S. Baseline anti-blood group antibody titers and their response to desensitization and kidney transplantation. Indian J Nephrol 2017;27:195-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Gundlapalli S, Rathi M, Kohli HS, Jha V, Sharma A, Minz M, et al. Efficacy of basiliximab induction in poorly matched living donor renal transplantation. Indian J Nephrol 2013;23:409-12.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Landin L, Rodriguez-Perez JC, Garcia-Bello MA, Cavadas PC, Thione A, Nthumba P, et al. Kidney transplants in HIV-positive recipients under HAART. A comprehensive review and meta-analysis of 12 series. Nephrol Dial Transplant 2010;25:3106-15.  Back to cited text no. 4
    
5.
Kumar MS, Sierka DR, Damask AM, Fyfe B, McAlack RF, Heifets M, et al. Safety and success of kidney transplantation and concomitant immunosuppression in HIV-positive patients. Kidney Int 2005;67:1622-9.  Back to cited text no. 5
    
6.
Roland ME, Barin B, Carlson L, Frassetto LA, Terrault NA, Hirose R, et al. HIV-infected liver and kidney transplant recipients: 1- and 3-year outcomes. Am J Transplant 2008;8:355-65.  Back to cited text no. 6
    
7.
Gruber SA, Doshi MD, Cincotta E, Brown KL, Singh A, Morawski K, et al. Preliminary experience with renal transplantation in HIV+recipients: Low acute rejection and infection rates. Transplantation 2008;86:269-74.  Back to cited text no. 7
    
8.
Barau C, Blouin P, Creput C, Taburet AM, Durrbach A, Furlan V, et al. Effect of coadministered HIV-protease inhibitors on tacrolimus and sirolimus blood concentrations in a kidney transplant recipient. Fundam Clin Pharmacol 2009;23:423-5.  Back to cited text no. 8
    
9.
Canaud G, Dejucq-Rainsford N, Avettand-Fenoël V, Viard JP, Anglicheau D, Bienaimé F, et al. The kidney as a reservoir for HIV-1 after renal transplantation. J Am Soc Nephrol 2014;25:407-19.  Back to cited text no. 9
    
10.
Takahashi K, Saito K. ABO-incompatible kidney transplantation. Transplant Rev (Orlando) 2013;27:1-8.  Back to cited text no. 10
    
11.
Jha PK, Bansal SB, Sethi SK, Jain M, Sharma R, Nandwani A, et al. ABO-incompatible renal transplantation in developing world - crossing the immunological (and mental) barrier. Indian J Nephrol 2016;26:113-8.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Campara M, West-Thielke P, Thielke J, Ommert T, Oberholzer J, Benedetti E, et al. ABO incompatible renal transplantation in an HIV-seropositive patient. Transplantation 2008;86:176-8.  Back to cited text no. 12
    




 

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