First HIV-positive heart transplant – with two-year successful follow-up

The 5 June edition of the New England Journal of Medicine includes a two-year follow-up report from the first successful heart transplant, in January 2001, in an HIV-positive individual.

The recipient was a 39-year-old research scientist who had been diagnosed HIV-positive in 1992 and his history of opportunistic infections including KS, gastrointestinal CMV, disseminated MAI and PCP. Nadir CD4 count was 0 cells/mm3 in April 1994.

Antiretroviral therapy included nucleosides only until 1995 and when the first protease inhibitors became available and CD4 count increased to 400 by 2000 with no additional OI complications.

Echocardiography in 1995 revealed an ejection fraction of less than 25%, which progressively fell to 10% by October 1999. Assessment included attributing dilated cardiomyopathy to previous use of daunorubicin treatment.

Viral load has been maintained <50 copies/ml since 1998 including throughout the transplantation and post transplant follow-up. CD4 count dropped to <50 cells/mm3 during the period immediately surrounding the operation, but did not result in recurrence of previous AIDS-related infections. Sensitive serial monitoring included PCR for HHV-8 (associated with KS).

The report notes that “the clinical course has been marked by frequent episodes of rejection (grade 0 to 3A), revealed by serial endomyocardial biopsies; these episodes have not been associated with haemodynamic changes and have been treated with intermittent glucocorticoids (the data are summarised in Table 1). Other complications after transplantation have included an exacerbation of gouty arthritis, recurrent anal condyloma, and the development in March 2002 of anaemia (hematocrit, 25%) that was initially attributed to distal esophagitis–gastritis on endoscopic examination in April 2002. The patient recently became transfusion-dependent, despite the resumption of erythropoietin therapy (Table 2), and currently requires transfusions of packed red cells every two to three weeks. However, he continues to work full-time and exercises regularly.

Notably, the HAART in this case is a full-dose ritonavir-based regimen, and even more surprisingly this continues today. The significant interactions with ritonavir and calcineurin antagonists used after transplantation required particularly careful adjustment.

Calabrese L, Albrecht M, Zackin R et al. Successful cardiac transplantation in HIV-1-infected patient with advanced disease, NEJM 2003;348:2323-2328

Comment

Access to, and more importantly successful results from, solid organ transplants have increased in the last five years, largely as a result of HAART therapy. HIV-positive people are no longer automatically excluded from life extending surgery because their lives are assumed to be too short to justify the costs involved.

Highest success rates have been reported with kidney transplants, and the growing success with liver transplants for people with ESLD caused by hepatitis C is still complicated largely by reinfection. Use of immune-suppressing drugs essential in all transplants do not appear to present increased risks for HIV-positive patients compared to people who are HIV-negative so long as they have a minimal baseline CD4 count (currently >200 cells/mm3 for kidney and >100 cells/mm3 for liver transplants).