Purpose: With the development of highly active anti-retroviral therapy (HAART) to treat HIV infection, HAART managed persons can now be expected to live longer than those in the pre-HAART era. As a result, many persons living with HIV infection will now experience end-stage organ failure (ESOF) well before they have life-threatening conditions related to this disease. Given the improved prognosis for people living with HIV infection and the burden of illness they may experience from ESOF, the benefit of solid organ transplantation to treat ESOF in this population needs to be determined. The purpose of this systematic review and meta-analysis was to determine the effectiveness of solid organ transplantation in persons with end stage kidney and liver failure and human immunodeficiency virus (HIV+).
Method: Multiple bibliography databases (e.g. OVID MEDLINE, EMBASE) were searched (“HIV”, “Liver, Kidney Transplantation) for potentially relevant citations (n=1204) from 1996 to 2009. Identified studies were full-text reviewed according to the pre-defined inclusion criteria i) RCT, observational studies, ii) HIV+ population receiving HAART with ESOF, iii) studies reporting Kaplan-Meier survival curve analysis, iv) minimum of 1-year follow, and v) English language. Study characteristics and survival curve data were extracted by one reviewer and verified by another. Quality of evidence was assessed using GRADE. Hazard ratio (HR) estimates were constructed from summary survival data, if necessary; they were combined into pooled HRs using random-effects models for the following outcomes: i) death after transplantation, ii) graft survival iii) HIV disease progression, iv) acute graft rejection, and v) recurrence of hepatitis C (HCV) infection.
Result: Fifteen studies were identified after full-text review. The quality of the evidence is very low. The risk of death after kidney transplantation does not differ between HIV-positive and HIV-negative study participants (pooled HR: 0.90 [95% CI: 0.36, 2.23]). The risk of death after liver transplantation is statistically significantly 64% higher for HIV-positive than HIV-negative participants (pooled HR 1.64 [1.32, 2.02]). The risk of death after liver transplantation is statistically significantly 2.8 fold greater in HIV/HCV co-infected participants than in HCV-positive mono-infected participants (pooled HR 2.81 [1.47, 5.37]).
Conclusion: Outcomes among HIV infected kidney transplant patients are not worse than uninfected patients; outcomes among liver transplantation patients appear to be worse. These conclusions are uncertain because of very low quality evidence.