In a first that gives
The transplant surgeries, which used organs donated by the family of an HIV-positive woman, ended a 25-year stretch in which the organs of HIV-infected people willing to donate them were rejected for use in transplants.
The experimental procedure follows the 2013 enactment of the HIV Organ Policy Equity Act, or HOPE, which repealed the ban on using such organs for transplantation.
"This is an unbelievably exciting day for our hospital and our team, but more importantly for patients living with both HIV and end-stage organ disease," said Dr. Dorry L. Segev, the Johns Hopkins surgeon who performed the surgeries.
"For these individuals, this could mean a new chance at life." Segev, professor of surgery at the Johns Hopkins University School of Medicine, also played a key role in designing and pushing the legislation that ended a 1988 prohibition on transplantation of HIV-infected organs.
Dr. Christine Durand, an infectious disease specialist at Johns Hopkins who now oversees the two transplant patients' care, said both of the recent transplant patients are doing well. The patient who acquired a new kidney 30 years after contracting HIV is already home from the hospital, she said.
The second patient, who has been HIV-positive for 25 years, remains in the hospital, Durand reported. But that patient's new liver, which replaces one that failed after complications from a hepatitis C infection, is "functioning extremely well," she added.
"We're encouraged by these first transplants," Durand said.
Alexandra K. Glazier, chief executive of the New England Organ Bank, which facilitated the organ donation, praised the "remarkable family who saw beyond their own loss" and agreed to the gift. The family declined to identify the organ donor but described her as "a daughter, a mother, an auntie, best friend and sister" who "was able to leave this world helping the underdogs she fought so hard for."
Under the HOPE Act, only transplant recipients who are HIV-positive are eligible to receive organs from HIV-positive donors. Still, the change is expected to make hundreds and potentially thousands of transplantable organs available each year to HIV-infected people with end-stage diseases of the kidneys, heart, liver or lungs.
While the Hopkins surgeries involved the use of organs from a dead donor, experts expect that living HIV-positive donors soon will step forward to offer a kidney for transplantation. Dr. Segev said that many HIV-infected donors are likely healthy enough to donate an organ without great risk to their health. Research protocols for the care of living HIV-positive donors, he added, will be drafted "over the next few months."
In the meantime, Segev urged those living with HIV to make clear to families and loved ones their willingness to become post-mortem organ donors.
As other transplant centers join Johns Hopkins in performing the procedures, the practice promises to shorten the line for all who await the call that a donor organ has become available.
There are 121,220 patients on the Organ Procurement and Transplantation Network's waiting list, and a name is added, on average, every 10 minutes. Each day, an average of 22 patients die waiting for an organ.
Of the close to 31,000 organ transplants performed annually in the United States, those involving organs from HIV-infected donors will remain a small minority. Experts estimate that each year, 500 to 600 HIV-positive people will die under circumstances that would make their organs available for transplant. As more HIV-infected patients on the waiting list receive organs, uninfected patients also will move up in line.
Segev predicted Wednesday that "as we get the word out, we'll have more and more donors become available," easing the shortage of organs. Prospective transplant patients living with HIV could elect to consider an HIV-positive organ and might find they get transplanted faster, he said Wednesday. Or they could continue waiting for an uninfected organ to become available.
Dr. David Klassen, chief medical officer of the United Network for Organ Sharing, said that key questions remain about the new generation of transplants, which are conducted under rules that treat them as research procedures. Among those are whether organs from HIV-positive donors will be as resilient as organs that have come from uninfected donors.
Klassen also said that in matching donors and recipients, physicians will have the added challenge of trying to ensure that an HIV-infected recipient does not get an organ from a donor infected with a more aggressive strain of the human immunodeficiency virus. In most cases, he said, that fit can be assumed if both recipient and donor have taken the same anti-viral medications and done well on them.
But in cases in which a donor's HIV infection is diagnosed at the time of his or her death, ensuring that match may not be possible, Klassen said.
Still, Klassen emphasized that the new procedures underscore how dramatically the prognosis for HIV-positive patients has changed.
"Certainly for years, when HIV first came on the scene, it was a fatal illness: Everybody that got it died," he said. HIV-positive patients were not likely to get listed on the wait list because their prognoses were poor, and the thought of using HIV-infected organs would have been unthinkable, he said. With the success of anti-viral cocktails in treating HIV-infected people, "patients really have good prospects for long-term survival," Klassen said.
"All these changes in transplantation are completely dependent" on those changes, he said. HIV-positive patients, who are at a higher risk of developing kidney failure because of the disease, have long been eligible to stand in line for transplanted organs alongside uninfected patients.
And at major transplantation centers, surgeons have substantial experience in performing surgeries on HIV-infected patients. Between 2005 and 2015, surgeons in the U.S. transplanted donated organs into at least 1,376 HIV-positive patients. Centers where those procedures have been performed will be the first to gain approval for transferring organs from HIV-positive donors to HIV-positive recipients.
While Johns Hopkins is the first transplant center to perform the experimental procedure, two others — Hahnemann University Hospital in Philadelphia and Mt. Sinai Hospital in New York — also have applied to perform such procedures as donor organs become available.
Segev called the surgeries, which took place a few weeks ago, "really only the beginning." In a bid to improve patients' outcomes, Johns Hopkins and 29 other hospitals will form a consortium to share their experience with these surgeries and others in which patients with HIV received uninfected organs.
The post-surgical treatment protocols for transplant patients living with HIV — including a lifelong regimen of immunosuppressive drugs — are a particular concern. But Durand said the record of success has been good.
"With careful selection and careful monitoring, this is a very safe and effective procedure for those with HIV," Durand said Wednesday.
As of late Tuesday, five HIV-positive transplant candidates were listed at approved centers for HIV-positive organs, according to UNOS spokeswoman Anne Paschke. Four were awaiting a kidney, and one awaits a donated liver, she said.
FOR THE RECORD
March 30, 1:29 p.m.: An earlier version of this article misspelled the last name of UNOS spokeswoman Anne Paschke as Plaschke.