KIDNEY TRANSPLANTATION FROM HBV-POSITIVE DONOR TO HIV-POSITIVE RECIPIENT: A CASE REPORT

Kidney transplantation is the preferred life-saving therapy for ESRD, surpassing hemodialysis in improving long-term survival, quality of life, and reducing healthcare costs. However, organ scarcity and prolonged waiting times pose critical challenges, risking patient mortality and impacting post-transplant outcomes.

We present a case of a 51-year-old female patient who sought kidney transplantation at our center due to ESRD with suspected chronic analgesic nephropathy. The patient had been managing HIV-1 infection since 2002 and was on Highly Active Antiretroviral Therapy (HAART). In 2019, the patient progressed to ESRD and initiated peritoneal dialysis. Despite encountering rejection from several transplantation centers due to her HIV-positive status, she was not enrolled in any waiting lists. Patient displayed an undetectable HIV-1 viral load, a CD4 count exceeding 200, and no history of Acquired Immunodeficiency Syndrome (AIDS) defining illnesses. Diligently adhering to her HAART regimen, comprising Raltegravir 50mg (RAL), Lamivudine 150mg (3TC), and Abacavir 300mg (ABC), she became a candidate for kidney transplantation. In consideration of her ESRD, ABC was chosen over Tenofovir (TDF) subsequent to a negative HLA-B 5701 test result. During the examination, her blood pressure and pulse rate were elevated at 150/80 mmHg and 115 bpm, respectively. However, other vital signs and examinations were within normal limits.

People living with HIV (PLWH) post-transplantation encounter unique challenges, including drug interaction management and increased rejection susceptibility. Success hinges on selecting HAART and immunosuppressive regimens that minimize drug interactions while ensuring optimal immunosuppression. Induction with antithymocyte globulin (ATG) not only diminishes the risk of acute rejection but also has a lower risk of infections compared to scenarios without induction. The common approach involves long-term maintenance therapy using a calcineurin inhibitor-based regimen Tac and MMF, with or without steroids. However, these medications often interact with HAART, potentially increasing toxicity or reducing immunosuppressant levels, especially with protease (PI) and non-nucleoside reverse transcriptase inhibitors (NNRTI). Notably, Integrase inhibitor-based antiretroviral regimens, paired with nucleoside reverse transcriptase inhibitors (NRTI), are preferred over PIs and NNRTIs due to their lower risk of interacting with immunosuppressive therapy and reducing rejection rates.

In the context of treating individuals with HIV-HBV coinfection, it is crucial to prioritize HAART that effectively targets both viruses, as advised by Department of Health and Human Services (DHHS) guidelines. This entails selecting specific antiretroviral drugs, such as emtricitabine (FTC), lamivudine (3TC), tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide (TAF), known for their dual efficacy against HIV and HBV. DHHS recommends using either TAF or TDF in combination with either 3TC or FTC as the NRTI backbone for a fully suppressive antiretroviral (ARV) regimen. However, if TDF or TAF pose safety concerns, entecavir, an HBV therapy with limited activity against HIV, may be considered as an alternative. Notably, when using entecavir in HBV-HIV coinfected patients who are not on ART, it must be supplemented with a fully suppressive ARV regimen to prevent the development of resistance mutations. Discontinuation of FTC, 3TC, TDF, or TAF may lead to HBV reactivation and subsequent hepatocellular damage, underscoring the necessity of maintaining these medications in the treatment regimen for coinfected individuals. Standard prophylaxis and post-transplant monitoring of HBsAg, HBV DNA, HIV-1 VL, and CD4 counts should align with established guidelines to vigilantly monitor opportunistic infections, HIV progression, and HBV reactivation.

In conclusion, to our knowledge, this is the first-ever case report detailing cross transplantation from an HBV-positive donor to an HIV-positive recipient. It underscores the crucial role of careful donor selection, precise recipient matching, minimal drug interactions, optimal HAART and immunosuppressive regimen adjustments, and effective prophylaxis against HBV reactivation and opportunistic infections in ensuring patient and graft survival.