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Longer-living HIV patients raise new transplant question
Tuesday, September 07, 1999 By Christopher Snowbeck, Post-Gazette Staff Writer
Francine Kohl is infected with HIV but can't stomach the wonder drugs that would help her fight AIDS -- her liver is stricken with hepatitis C. And she has had trouble getting a new liver because most hospitals won't provide transplants for HIV-positive patients.
The only way out of this Catch-22 was for Kohl to travel from her home in New York City to the University of Pittsburgh Medical Center, one of the few centers that transplants HIV-positive patients. She's now one of four patients infected with the human immunodeficiency virus awaiting either a liver or kidney transplant at UPMC.
In the case of the other transplant centers, she said, "it's like they won't give me a liver transplant because I have HIV, and it's not worth saving my life." A recovered drug addict and alcoholic, Kohl, 56, believes she contracted HIV via a dirty hypodermic needle.
Until recently, life expectancy was so short for people with HIV that hospitals didn't even consider giving them transplants. But improvements in AIDS drugs have caused some hospitals to reconsider. What's more, with more HIV patients living longer, more are likely to experience liver failure and thus require liver transplants, especially because there is significant overlap in patients with HIV and those with hepatitis C.
The ramifications for surgeons seem clear.
"It's difficult to deny a patient a transplant when we have a life expectancy of 15 years," Dr. Gunnar Soderdahl, a transplant surgeon from Huddinge, Sweden, said during an International Liver Transplantation Society meeting here last month.
But the prospect of making a whole new group of patients eligible for transplant raises questions about how best to manage the meager supply of available organs.
"It seems almost crazy to be exploring new possibilities for transplant when the shortage is so severe," said Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania. "It's certainly the case that you don't want to discriminate against anybody, but you want to take into account the chances of success and the likelihood that people will live with the transplant."
The conclusion of three surgeons at the international meeting in Pittsburgh last month -- including Soderdahl, Dr. Nigel D. Heaton of King's College Hospital in London and Dr. John Fung, the chief transplant surgeon at UPMC -- was that a few transplant centers should move forward with studies to find which HIV-positive patients fare well with transplants.
Fung reported that three of four HIV-positive patients who received liver or kidney transplants in the past two years at Pitt are still alive. Two have been treated for recurring hepatitis C, but all three have excellent liver function. None has had problems related to the HIV, and all have undetectable levels of HIV.
The patient who died was too far along with liver disease for the transplant to do much good, Fung said.
Heaton reported that some of the five HIV-positive patients transplanted at his hospital since 1996 also have had problems with hepatitis C, but not HIV-related illnesses.
This week, Fung will join transplant doctors from the University of California at San Francisco and New York's Mount Sinai School of Medicine for a meeting organized by the National Institutes of Health. The purpose is to reach consensus on what further clinical studies make sense, said Dr. William Duncan, associate director for the therapeutics research program at the National Institute of Allergy and Infectious Diseases.
Currently, NIH doesn't have any initiative to fund a study on transplanting HIV-positive patients, he added.
"I think the major issue for the group to discuss is, what are the appropriate populations that are optimum candidates for transplant," Duncan said.
Take the case of Kohl, the woman from New York.
Because she has been unable to take the most advanced medical treatments for HIV, the amount of the AIDS virus in her system is quite high. Kohl still has a relatively high number of CD4 cells, which fight infections, but because the virus is replicating she wouldn't be a candidate for transplant even at some of the centers that transplant people with HIV.
At the University of Minnesota, for example, doctors require that HIV-positive patients have undetectable levels of the virus, a relatively normal amount of CD4 cells and no AIDS-defining illnesses.
Those criteria also apply to HIV-positive patients who are being considered for transplant at the University of California at San Francisco, according to Dr. Peter Stock, a transplant surgeon there. The medical center plans up to 10 liver and kidney transplants in HIV-positive patients with a $1 million state grant.
But at UPMC, Fung is not sure that viral replication should necessarily disqualify a patient for a transplant. A patient like Kohl, for example, hasn't been treated with the new AIDS drugs and, therefore, should be a good candidate for the medicines once her liver problems are resolved. Fung said he probably wouldn't transplant a patient whose CD4 cell count is below 150.
"There are no rules in this -- this is all sort of new," he said.
The HIV discussion is set against the backdrop of a chronic shortage of livers available for transplant. More than 13,600 people are waiting for liver transplants, according to the United Network for Organ Sharing. Last year, there were 4,450 liver transplants performed across the country, but 1,319 people died waiting.
If transplant surgeons want to start adding HIV-positive patients to the waiting list, they might want to consider using organs from HIV-positive donors, said Caplan, the bioethicist at Penn.
"You'd just have to have a really good informed consent form for the recipient," he said. "You'd be asking someone to go through a hellish surgical procedure, paying a quarter million to a million dollars for an operation where you just end up trading terminal diseases."
Fung doesn't think that's necessary.
He believes that many organs suitable for transplant are lost every year because surgeons and organ procurement organizations choose not to recover organs from donors who have a high risk of HIV exposure, such as IV drug users and recently incarcerated men.
Prior to a transplant, doctors perform tests that eliminate most questions about whether an organ is infected with HIV, but the tests aren't sensitive enough to eliminate all worries about organs from these high-risk individuals. Fung proposes that these organs be directed to HIV-positive recipients who say they are comfortable with the risks.
"A lot of these are very young donors with very excellent organ function," he said.
Although other doctors and organ procurement officials say this potential source of organs isn't rich, Fung believes the separate channel could provide enough livers and kidneys for the one- to two-dozen HIV-positive patients per year that he believes should receive experimental transplants.
One question with transplanting HIV-positive patients is how anti-rejection drugs will affect the already-compromised immune systems of HIV patients. In other words, will immunosuppression -- which is essential to a transplant -- allow the AIDS virus to spread?
Experience with the limited number of patients to date suggests the answer is no, Fung said. Two HIV-positive recipients who were transplanted at UPMC years ago -- one who became infected after transplant and one whose infection was undetected at the time of transplant -- have lived for about 15 years each.
"These patients can live quite a while," Fung said.
Allen Hext 45, of Palm Springs, Calif., can't boast of such a track record, having received his liver transplant at UPMC only last December. But for now, he feels better than he has in 10 years.
Hext was diagnosed with HIV in 1988. He later developed hepatitis C, probably due to a transfusion, he said. By the time of his transplant, the hepatitis made him feel like he was at death's door. Now, however, he is a new father, his liver is functioning and the amount of HIV in his system is undetectable.
"I went to places locally ... and they said no one would pay for the transplant because I'm HIV positive and it wasn't part of their protocol," he said. "Basically, they're saying, why should we give you a liver when someone else needs one who has so many fewer problems. ... Who draws the line? You're playing God here."
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