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Breaking Boundaries: Heart Transplantation in HIV-positive Recipients


Suneet Purohit, MD
Suneet.Purohit@ucdenver.edu

Natasha Altman, MD
Natasha.Altman@ucdenver.edu
University of Colorado Denver
Denver, CO, USA



Even with advances in treatment, the long-term morbidity and mortality of heart failure remains high, and potential heart transplant recipients are becoming increasingly medically complex. Transplant centers are progressively treating heart failure patients not only for diabetes, hypertension and renal insufficiency, but also for chronic infectious comorbidities such as HIV and Hepatitis C. The prevalence of heart failure is significantly higher in HIV-infected patients than in non-HIV infected patients [1]. Current highly active antiretroviral therapy (HAART) regimens are able to suppress HIV viral loads to levels that enable patients to live longer with fewer side effects [2]. As a result, HIV is no longer considered a contraindication to heart transplantation [3]. However, cardiac transplantation is still infrequently performed in this patient population [4]. We present the case of a 53-year old male with HIV who recently underwent a cardiac transplant at our institution. The patient has given permission to share his case.

Our patient is a 53-year old male with history of New York Heart Association class IV systolic heart failure, monomorphic ventricular tachycardia status post biventricular ICD placement, HIV on HAART therapy, hypothyroidism and chronic kidney disease. Initially, he was referred to our institution from an outside facility due to progressive heart failure symptoms from multiple episodes of volume overload and ventricular tachycardia. He was diagnosed with HIV in 1995 in the setting of intravenous methamphetamine use. He was hospitalized in 2001 for pneumocystis pneumonia and cryptosporidium, whereupon he was started on HAART. He was managed at outside institutions for years and was referred for evaluation of his worsening heart failure. Upon our initial evaluation, he had been free of illicit drug use since 2001; HIV viral load had been undetectable for over 4 years, and his CD4 count was 429 on a HAART regimen of Viramune and Epzicom. After discussion with the infectious diseases team, the patient's HAART regimen was adjusted to abacavir/dolutegravir/lamivudine combination therapy for ease of use and to enable integrase inhibitor use. Protease inhibitors were avoided due to their interactions with calcineurin inhibitors. For multiple hospitalizations for volume overload and increasingly difficult to control ventricular tachycardia, he was listed and underwent successful cardiac transplantation in September 2017. His early post-transplant course has been smooth with no graft dysfunction and no evidence of significant cellular or antibody mediated rejection, which has enabled his prednisone to be tapered. His HIV viral load remains undetectable and there have been no significant interactions with his HAART medications and immunosuppressant regimen of tacrolimus and mycophenolate mofetil.

Our patient's case demonstrates the resolvable challenges in transplanting HIV positive patients in an era of post-transplant immunosuppression and improving HAART therapies, employing a multidisciplinary team of cardiologists, infectious disease specialists and pharmacists. The use of integrase inhibitors such as raltegravir or dolutegravir have markedly decreased the risk of drug-drug interactions with immunosuppressants, since neither affect the CYP450 system which enables continuation of HAART therapy post-transplant [5]. Post-transplant antimicrobial prophylaxis for opportunistic infections is the same as for HIV and non-HIV infected patients as well. Data from other transplant centers show that while cardiac transplantation of HIV patients is still rare, 1 and 3-year survival rates are comparable to non-HIV infected patients [6]. The 2016 ISHLT guidelines have been updated to include transplantation of HIV positive patients as a Class IIa indication provided there is no evidence of active or prior opportunistic infection, CD4 count > 200 cells/µl, and the HIV viral load remains undetectable > 3 months while compliant on HAART therapy [3].

Equipoise is one of the guiding principles in organ allocation networks. The limited data available on cardiac transplantation in HIV positive patients demonstrates that HIV infected patients derive the same benefit from heart transplants as non-HIV infected individuals with minimal difference in outcomes. Therefore, consideration of HIV-infected patients with well-controlled disease is reasonable enough to allow equal access to the scarce resource of cardiac transplantation. ■

Disclosure Statement: The authors have no conflicts of interest to disclose.


References:

  1. Kendall CE, Wong J, Taljaard M, et al. A cross-sectional, population-based study measuring comorbidity among people living with HIV in Ontario. BMC Public Health 2014; 14: 61.
  2. van Sighem AI, Gras LA, Reiss P, Brinkman K, deWolf F; ATHENA national observational cohort study. Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. AIDS 2010; 24 (10):1527-35.
  3. Mehra MR, Canter CE, Hannan MM, et al. The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: a 10-year update. J Heart Lung Transplant. 2016; 35:1-23.
  4. Uriel N, Nahumi N, Colombo PC, et al. Advanced heart failure in patients infected with human immunodeficiency virus: Is there equal access to care? J Heart Lung Transplant 2014; 33: 924-930.
  5. Miro JM, Aguero F, Duclos-Vallee JC, et al. Infections in solid organ transplant HIV-infected patients. Clin Microbiol Infect. 2014; 20(7): 119-130.
  6. Aguero F et al. An update on heart transplantation in human immunodeficiency virus-infected patients. Am J Transplant. 2016; 16 (1):21-8.



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