 Organ
Transplants
Promising news for positive people.
by Enid Vázquez
Gone are the days when transplant centers
refused patients with HIV. Today, it’s common knowledge
that with the powerful HIV medicine available, people living
with the virus can expect a much longer and healthier life,
making the arduous job of a transplant more feasible.
“Most transplant centers are not looking
at HIV as a contraindication [two things that don’t go
together], but as a challenge,” says Dr. Patrick Lynch,
a hepatologist at Northwestern Memorial Hospital in Chicago.
“Although not everyone with HIV will meet all the criteria
for a transplant, it’s good to know that it’s available.”
It’s especially good news as conditions
like liver disease and viral hepatitis become a greater risk
for death in people with HIV. Moreover, not only do non-HIV
related conditions become a greater risk as treatment successfully
wards off the complications of AIDS, but the treatment itself
may contribute to disease. The medications might, for example,
lead to stress on the liver.
Dr. Lynch notes that 30% of people with
HIV will have some form of liver disease, usually with infection
by either hepatitis B or hepatitis C.
According to the National Organ Transplant
Act (NOTA), people with HIV who are asymptomatic (without
symptoms of disease) “should not necessarily be excluded
from candidacy for organ transplantation.” NOTA goes
on to state that these persons “should be advised that
he or she may be at increased risk of morbidity and mortality
because of immunosuppressive therapy [required for all transplant
patients].” It also says that, “Administering treatment
to patients who test positive for the HIV antibody should
not be optional or discretionary for health care personnel.”
In other words, NOTA advocates a non-discriminatory policy.
Evaluation
Once a person receives a diagnosis of
end-stage disease, he or she can request an evaluation at
a transplant center. There are 200 around the country, and
each has its own criteria.
The Kovlar Transplant Center at Northwestern
is currently evaluating and putting people with HIV on the
liver transplant list. The center plans to do more liver and
kidney transplants in the future. They are also conducting
a study to evaluate the interactions between HIV medications
and drugs used to prevent organ rejection after a transplant.
(As this will require post-transplant blood work, HIV-positive
patients with transplants from other Chicago area centers
can join this study.)
“We have the transplant expertise
and the HIV expertise. We have Rob Murphy and other infectious
disease doctors who’ve conducted groundbreaking ACTG
[AIDS Clinical Trials Group] studies. We’re excited about
combining the two fields of expertise,” says Dr. Lynch.
“Additionally, we are looking into new ways to expand
the number of organs available for transplant. We were the
first center in Chicago to do living donor liver transplants
as well as the first center to do a liver transplant in someone
infected with HIV. We are also involved in changing the state
law to increase the number of organs available for liver transplantation.”
Dr. Lynch advises that you select “a
center with experience in HIV because both conditions need
to be treated well afterwards.” He further suggests that
you look for the centers interested in HIV-positive transplants
and that you ask for referrals to other centers if you’re
rejected.
He also points out that a center closer
to home is important, because post-operative care might require
daily visits for a time, and because being far from home puts
an extra burden on family members and other support people.
Time—and research—will tell
“Experimental” procedures
leave the realm of the experimental after a significant amount
of work takes place—with the help of solid research.
It’s in this area that HIV-specialists
from the University of California at San Francisco (UCSF)
are leading the way. Doctors at UCSF successfully struggled
to establish a large, multi-center study on transplants in
HIV-positive people. This trial opens 17 centers around the
country to people with HIV (see box). As with the trial at
Northwestern and at other centers, this research seeks to
determine the best way to make transplants successful for
people with HIV.
This does not mean that people with HIV
will be able to receive an organ any faster than anyone else.
What is does mean is that is that this rigorously designed
trial will look at the transplants from A to Z, collecting
the information needed to make transplants work best for people
with HIV. If it turns out that these transplants are safe
and effective, such data should also help put to rest battles
for reimbursement from Medicare and private insurance. Also,
without a study, transplants can be done in HIV-positive people,
but the knowledge gained is either lost or reported after
the fact such as with a case report or a chart review—not
the best way to advance scientific information.
Study co-chair Dr. Michelle Roland, an
assistant professor of medicine at UCSF at the Positive Health
Program at San Francisco General Hospital, points out that
there are other studies being conducted as well, and that
people with HIV should investigate all of their options. She
notes, however, that some of the centers in this study have
the most experience in this work. “This is a new area
and there are a lot of things to learn. It could be that a
center doing this for the first time can do it perfectly.
Most people, however, can expect to do better with a center
that has a high volume vs. one with a low volume of any particular
procedure, such as a by pass.”
Dr. Roland and her colleagues have published
several papers and presented reports on their work. In their
papers, the researchers note that transplants may be a good
option for HIV-positive people who are “relatively healthy.”
This is an important distinction. “End-stage liver disease
is different from end-stage HIV disease in the context of
transplants. We don’t include people with advanced HIV
disease in our study,” she explains. Dr. Roland stressed
that people with HIV “do everything they can to prevent
a transplant.”
A few suggestions: get screened for hepatitis
B and C, get vaccinated for hepatitis A and B, and have your
doctor monitor your liver enzymes and other blood work on
a regular basis. Says Dr. Roland, “Transplantation is
a very serious endeavor. While it’s very exciting that
this option is available, you would rather not have to exercise
this option and take all these meds with all these toxicities
for life.”
If you do need a transplant, she advises
that you get evaluated for one early after you receive that
diagnosis, not wait until you’re very sick.
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