Solid Organ Transplantation In The HIV‐Infected Patient

Publication Date: April 1, 2019
Last Updated: March 14, 2022

Recommendations

RISK FACTORS

HIV‐infected patients should be on a stable cART regimen with no evidence of viremia and a CD4 count ≥200 cells/mm3 for all except liver candidates in whom a CD4 count ≥100 cells/mm3 can be considered. (Moderate, Strong)
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HIV‐infected liver candidates who cannot tolerate cART due to advance liver disease can be considered for transplantation if they have evidence of an easily controllable HIV infection based on genotypic and/or phenotypic assessment. (Low, Weak)
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HIV‐infected candidates who are co‐infected with HCV can be considered for transplantation assuming there is a plan for treatment of HCV either prior to transplant or in the early post‐transplant period.

(Low, Strong)
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DIAGNOSTIC STRATEGIES POST-TRANSPLANT IN THE HIV‐POSITIVE RECIPIENT

All candidates for kidney transplantation with hepatitis co‐infection should undergo assessment of liver disease with either transient elastography or liver biopsy prior to listing, and patients with cirrhosis should be carefully evaluated for hepatic decompensation and potentially excluded from kidney transplantation unless they could be considered for combined liver and kidney transplantation. (Low, Strong)
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Biopsy should remain the gold standard in assessing graft dysfunction in HIV‐infected individuals. (Moderate, Strong)
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HIV RNA and CD4+ T‐cell counts should be monitored 1‐month post‐transplant and then every 2‐3 months post‐transplant to insure control of HIV. (Low, Strong)
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Individuals with persistent HIV viremia should undergo genotypic and phenotypic testing for resistance. (Moderate, Strong)
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Use of archival resistance testing should be considered prior to modifying cART regimens due to drug intolerance or interactions when HIV VL is suppressed. (Very Low, Weak)
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TREATMENT CONSIDERATIONS IN THE HIV‐POSITIVE TRANSPLANT RECIPIENT

Induction therapy with either lymphocyte depletion or interleukin 2 receptor antagonist should be used. (Moderate, Strong)
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Lymphocyte‐depleting induction is recommended for high immunologic risk candidates (African American, presence of donor specific antibodies, prior transplant). (Moderate, Strong)
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Maintenance immunosuppression regimens for kidney recipients should include tacrolimus, a mycophenolate analog, and long‐term corticosteroids. (Moderate, Strong)
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Steroid avoidance regimens should not be used given the increased risk of rejection. (Very Low, Strong)
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Protease inhibitor‐based regimens and cobiscistat should be avoided. (Moderate, Strong)
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Regimens avoiding these medications should be implemented prior to transplant, unless there are no alternative options based on genotypic and phenotypic testing. (Moderate, Strong)
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If use of a protease inhibitor or pharmacokinetic enhancer such as cobicistat is necessary, significant dose reductions of calcineurin and mTOR inhibitors are necessary. Daily monitoring of levels is required to determine optimal dosing. (Moderate, Strong)
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Use of an integrase inhibitor‐based cART regimen is preferred due to the favorable safety profile and lack of DDIs. (Moderate, Strong)
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Transplant recipients co‐infected with HBV and HIV should receive cART that includes two drugs with activity against HBV. (High, Strong)
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Tenofovir alafenamide is preferred to tenofovir disoproxil fumerate because of its improved safety profile. (Low, Strong)
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All patients co‐infected with HIV and HCV should be treated with DAAs for HCV. (High, Strong)
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The timing of HCV treatment in non‐liver recipients should be determined based on the degree of liver disease, the likelihood of earlier transplant with an HCV‐positive organ, and the availability of DAA therapy. Treatment can be deferred to the early post‐transplant period in stable patients in whom HCV‐positive organs are readily available. (Moderate, Strong)
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PREVENTIVE MEASURES IN THE HIV+TRANSPL ANT POPULATION

All HIV‐infected transplant recipients should receive standard institution‐based prophylaxis for against Pneumocystis, cytomegalovirus, and fungal pathogens. (Moderate, Strong)
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The need for extended Pneumocystis prophylaxis beyond 1 year should be weighed against therapy‐related adverse effects that may warrant early discontinuation. (Low, Weak)
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Primary and secondary prophylaxis against opportunistic pathogens in HIV‐infected transplant recipients should be initiated in accordance with national HIV guidelines. (Moderate, )
(moderate)
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Vaccine recommendations for HIV‐infected transplant candidates and recipients should mirror those of HIV‐uninfected transplant candidates and recipients. (Moderate, Strong)
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Live vaccines should be avoided in most cases (see Vaccine section of 4th edition of AST ID Guidelines). (Moderate, Strong)
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HIV TO HIV TRANSPLANTATION

With approval of the HOPE Act, transplantation of HIV‐infected organs into HIV‐infected recipients may be performed under specific research criteria. (Moderate, )

(moderate)

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Recommendation Grading

Overview

Title

Solid Organ Transplantation In The HIV‐Infected Patient

Authoring Organization

American Society of Transplantation

Publication Month/Year

April 1, 2019

Last Updated Month/Year

March 16, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the management of transplantation in HIV‐infected individuals.

Target Patient Population

Patient with HIV undergo solid organtransplant

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D014180 - Transplantation, D066027 - Transplant Recipients, D015658 - HIV Infections, D006678 - HIV

Keywords

human immunodeficiency virus (HIV), HIV infections, solid organ transplant