Figure 1052

The occurrence of AIDS in HIV-infected transplant recipients according to immunosuppressive treatment. Immunosuppression included cyclosporine in 40 individuals and no cyclosporine in 13 individuals.

The precise natural history of HIV infection following renal transplantation is still not well delineated. The largest single series from Pittsburgh analyzed 11 patients who were HIV positive prior to transplantation and 14 patients who developed HIV infections following transplantation. Of the 11 patients infected before transplantation, six were alive an average of 3.3 years following transplantation. Five patients had died, however; three of AIDS-related complications. Of the 14 patients infected peritransplantation, seven patients were alive at follow-up an average of 4.8 years later. There had been seven deaths, three due to AIDS. Complications seemed to correlate with increased immunosuppression for rejec tion. Another report evaluating 53 patients infected with HIV around the time of transplantation found that patients treated with cyclosporine appeared to have a better long-term prognosis than those who were treated with prednisone and azathioprine.

In summary, although there are no firm conclusions, it appears that there is not much difference between pre- or post-transplant acquisition of HIV infection, although some authors, based on small numbers of patients, have concluded that the age of the patient and the duration of the infection are both prognostic factors. It also appears that approximately 25% of HIV-infected individuals do poorly within the first 6 months of transplantation, especially following antirejection treatment (Rubin, unpublished data). Another 25% of individuals appear to do very well 6 years and beyond following transplantation. The remainder of the individuals seem to develop AIDS within 3 to 3.5 years after transplantation, with an average survival of about 3 months after the onset of AIDS. It has also been noted that cytomegalovirus or other infections that may increase HIV proliferation may influence this outcome, and that prophylactic antimicrobial strategies may alter the "natural history. "

Currently, it is advised that all transplant candidates be screened for the presence of HIV antibody and counseled about the possible consequences of further immunosuppression, but not be categorically denied transplantation if they are otherwise asymptomatic. Patient management following transplantation should be focused on the avoidance of large increases in immuno-suppression and opportunistic infections, with special attention to the viral, pneumocystic, and mycobacterial infections that these individuals may develop. Antiretroviral strategies in transplantation require study. (Adapted from Schwarz and coworkers [30]; with permission.)

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