Solid Organ Transplant

SOT in PLWH

General features

  • HIV infection is not a contraindication for transplantation consideration
  • Experts in HIV medicine should preferably be members of the multidisciplinary team, responsible for the pre-transplant evaluation, and take primary responsibility for the management of the HIV infection and the prevention and treatment of OIs

Organ criteria

  • PLWH should be considered for organ transplantation using the same indications as used in HIV-negative persons. PLWH with HCC can be evaluated for liver transplantation if they fulfill the Milan criteria
    • Milan criteria: solitary tumor smaller than 5 cm or 2 - 3 tumors of < 3 cm in the absence of macrovascular tumor invasion and extrahepatic metastases

Organ donation

  • PLWH can receive organs from living (renal) and deceased (all types of SOT) HIV-negative donors
  • In some European countries the use of organs from HIV-positive donors is allowed but the efficacy and safety of this approach is currently being evaluated in the context of research studies

HIV-infection criteria

  • According to most international guidelines, PLWH should fulfill the following criteria to be considered for SOT
  1. Clinical criteria. No active OIs or HIV-related cancers. Individuals with PML, chronic crypto/microsporidiosis, multi-drug resistant fungal or mycobacterial infections, NHL and visceral KS to be excluded. For non-HIV-related cancers same criteria apply as in the general HIV-negative population
  2. Immunological criteria. CD4 > 200 cells/µL for all SOT except for liver transplantation where CD4 > 100 cells/µL. Persons with previous opportunistic infections should have a CD4 > 200 cells/µL
  3. Virological criteria. Full control of HIV replication prior to and after transplantation should be confirmed/predicted in all cases
  4. Drug abuse. Abstinence period: alcohol 6 months; heroin/cocaine 2 years. Former IVDUs can be in methadone programme

Transplant Preparation

Preparing PLWH for transplantation

Antiretroviral therapy

  • Choice of ART components should avoid drugs known to cause organ dysfunction or drugs with a high potential for drug-drug interactions if at all possible, see Drug-drug Interactions between Immunosuppressants (for SOT) and ARVs
  • Using a pharmacological booster (RTV or COBI) and some of the NNRTIs are best avoided, see Drug-drug Interactions between Immunosuppressants (for SOT) and ARVs
  • For individuals nearing indication for transplantation, ART should be modified to ensure this if at all possible
  • RAL (and probably DTG) plus 2 NRTIs is the preferred regimen
  • If the individual has not yet started ART and transplantation is considered, ART should be commenced as soon as possible and preferably before the transplantation is started

Viral hepatitis co-infection

  • In liver transplant candidates, every effort should be made to treat the underlying viral hepatitis independently of MELD score, see Treatment of HBV/HIV Co-infection and Treatment of HCV/HIV Co-infection. Use of DAAs in persons with HCV co-infection may improve their liver function, and possibly lead to them being removed from the transplant waiting list

Prevention of infections

  • While screening and treatment for latent TB is recommended in all PLWH, see Diagnostic and Treatment of TB in PLWH, it is particularly important in persons pre-and post-transplantation due to the additional use of immunosuppressants. Immunisation regimens and pre-transplant diagnostic protocols are the same as in HIV-negative SOT recipients

Post-transplant Follow-up

Antiretroviral therapy

  • Same recommendations in individuals under preparation for transplantation
  • Additionally, ARVs may exacerbate immunosuppressive agents’ adverse drug effects (kidney impairment, bone marrow suppression, drug-induced liver injury, etc.). Therefore, careful consideration of which drugs to use is essential see Adverse Effects of ARVs & Drug Classes
  • TAF is preferred to TDF, when available, to reduce additive nephrotoxicity to immunosuppressant agents

Prophylaxis

  • Primary and secondary disease-specific chemoprophylaxis
    • Transplant recipients living with HIV should receive the same surveillance, prophylaxis and immunisation regimens for OIs as HIV-negative SOT recipients
    • Screening and treatment for latent TB is a priority, see Diagnostic and Treatment of TB in PLWH.

Viral hepatitis co-infection

  • The efficacy and safety of DAAs in liver transplant recipients living with HIV with HCV recurrence is the same as in HIV-negative recipients
  • Anti HBV treatment should follow the same schedules of HIV-negative persons

Immunosuppression