Living-related donor renal transplantation in HIV+ recipients using alemtuzumab preconditioning and steroid-free tacrolimus monotherapy: a single center preliminary experience.

There are an estimated 40 million people infected with human immunodeficiency virus (HIV) around the world, with an incidence of 5 million new cases in 2003 (1). End-stage renal disease (ESRD) is an increasingly common problem in this growing patient population. Furthermore, the survival of patients infected with HIV who are on chronic hemodialysis is poor (2). Until recently, HIV-infected patients have generally not been considered candidates for renal transplantation (3). Before the introduction of highly active antiretroviral therapy (HAART), the substantially elevated morbidity and mortality associated with HIV infection was considered a contraindication to transplantation in most centers. The use of HAART has markedly decreased the rate of opportunistic infection and the overall mortality (4,5). This has prompted renewed interest in solid organ transplantation in this population. Despite improvements in survival with the use of HAART, there is still an increase in morbidity and mortality associated with HIV infection, and it has been difficult to justify the use of scarce deceased donor organs for transplantation into these patients (6). The utilization of living-related donor organs represents a way of providing organs for patients infected with HIV without further depleting the already short supply of deceased donor organs. Since its introduction in 1995, laparoscopic live donor nephrectomy (LLDN) has been shown to have a number of advantages over the traditional open operation (7). Patients experience less postoperative pain, shorter hospital stays, and shorter recovery times before returning to work (8, 9). In addition, because of the elevated risk of opportunistic infection and the risk of progression to AIDS, subjecting patients infected with HIV to pharmacologic immunosuppression has raised some concerns about the safety of renal transplantation in these patients. The avoidance of posttransplant over-immunosuppression is thought to permit the induction of partial tolerance (10). Recent data demonstrate that recipient pretreatment with rabbit anti-thymocyte globulin (Thymoglobulin), a T-cell depleting agent, followed by minimal use of posttransplant immunosuppression, permits a dramatic ability to wean immunosuppression (10, 11). More recently, preconditioning with alemtuzumab (Campath-1H, Millennium Pharmaceuticals, Cambridge, MA), a humanized anti-CD52 monoclonal antibody (12, 13), has been used instead of Thymoglobulin (14), with excellent early outcomes. A similar approach may be of benefit in HIV+ patients by permitting the weaning of maintenance immunosuppression. Here we present a total of seven consecutive cases of HIV+ patients who underwent renal transplantation at the University of Pittsburgh Medical Center from 1998 to the present. All seven patients had undetectable viral loads and CD4 counts over 200 cells/mm3 before transplantation. Four deceased donor recipients and three cases where LLDN was utilized to obtain the kidney for transplantation into living-related (sibling) recipients infected with HIV are described.