From left, Dr. Richard Dickerman, Dr. Jose Castillo-Lugo and Dr. Edward Dominguez at the Transplant Institute, Methodist Dallas. (David Taffet/Dallas Voice)
People who are HIV-positive can save someone’s life by signing up to be an organ donor
DAVID TAFFET | Senior Staff Writer
Once advances in medications turned HIV into a treatable disease, HIV became the sixth leading cause of kidney disease, according to Dr. Edward Dominguez, the medical director of Organ Transplant Infectious Disease at Methodist Dallas Medical Center. That means that kidney and liver donors are needed. Living donation is possible with both of those organs.
And since Methodist Dallas has joined HOPE, the HIV Organ Procurement Equity, that means if you have HIV, you can become an organ donor for other people living with HIV whose organs are failing, and the organs you donate may be used by someone at Methodist Dallas or they may be taken to another HOPE facility elsewhere in the country.
Dominguez said some of the first transplants in people with HIV were done in the 1990s among patients who didn’t know they were HIV-positive. And, he said, “They did very well.”
By the late ’90s, kidneys for people with HIV were offered for study.
As more transplants into people with HIV were performed, the results were comparable to transplants into people who are HIV-negative. Then studies of positive-to-positive transplants here and in South Africa replicated encouraging results.
In 2006, Methodist Dallas had applied to be part of a protocol to do transplants from HIV-positive donors into HIV-positive recipients. Methodist Dallas transplant surgeon Dr. Richard Dickerman, who has performed more than 3,000 kidney transplants, performed his first transplant into an HIV-positive patient in 2009. Since then, he’s done 18 such transplants.
But until 2016, organ transplants outside the protocol into people with HIV were still illegal. That’s when, at the urging of the American Society of Transplantation, President Barack Obama signed legislation that allowed transplanting organs into people who are HIV-positive.
To qualify for a transplant, a patient’s HIV must be under control. Still, transplant patients take drugs to suppress their immune system so their bodies don’t reject the new organs, and a goal of HIV medication is to help the immune system recover. So some of the original HIV-positive transplant patients were doing so well on their HIV meds that they were rejecting their new organs.
But as Dominguez explained, there’s a difference between being immunosuppressed and being immunodeficient. If all transplant patients had their immune systems suppressed to the point of immunodeficiency, they would contract the same opportunistic infections that were killing people with HIV before HIV meds were available.
So, Dominguez explained, “We bring [a transplant patient’s immune system] down, but not too low. Now we can adjust the net state of immune suppression.”
And with more recent medications, it’s become easier to adjust to the right level of immunity for the patient.
HIV medications fight the replication of the virus and the destruction of CD4 cells. But the immunosuppressants taken by organ transplant recipients prevent rejection by lowering the level of CD3 cells. The bonus, Dominguez explained, is that the same medication also seems to attack the HIV virus or keep it under control.
There are a few other tricks to keeping an HIV-positive transplant patient healthy. Dominguez said these patients are kept off protease-based regimens and can’t use Truvada, currently the most popular HIV medication. Although that means no one-pill cocktail, there are new classes of medications keeping transplant HIV patients healthy.
Other than finding the right drug regimen and that optimal level of immune suppression, treatment for an HIV-positive organ recipient is the same as for an HIV-negative transplant recipient. In fact, medically speaking, nothing makes those who are HIV-positive with kidney disease stand out. People with HIV are coming in with the same problems as people who are HIV-negative.
Dickerman said that means medically and procedurally, the transplant is the same. Medical professionals have always taken tremendous precaution in the operating room while doing a transplant: “We treat all patients as if they have HIV,” he said. “We wear eyewear, gloves and gown.”
Dr. Jose Castillo-Lugo, a nephrologist at Methodist Dallas, runs the HOPE transplant program there. He said allowing transplants of organs from someone with HIV to someone with HIV opens new doors of donors. “It’s going to change the practice around the world,” he added.
The age of an HIV-positive donor is younger than the general donor population, and a younger kidney begins to function after transplant faster leading to a faster recovery. Also, that younger organ should remain healthy longer, doctors said.
So far, 90 patients have received organs from 60 donors through the HOPE program. In addition to kidneys, livers may be transplanted from HIV-positive patients into HIV-positive patients, and Dickerman has performed three of those transplants.
A number of factors are involved in matching donors to recipients, such as blood type and tissue type matching. Body sizes also need to be comparable between donor and recipient, so that the donated organ fits properly in the recipient’s body.
Age is another important factor. Dickerman said he can’t transplant a 65-year-old kidney into a 30-year-old’s body, because by the time the recipient turns 65, his kidney would be 100 years old. On the other hand, doctors aren’t likely to transplant a teenager’s organ into an elderly person that has a much shorter expected lifespan.
Distance between the donor and the recipient also has to be considered. Some organs like kidneys can survive outside the body longer than others, so a kidney donor in one location might be able to save the life of someone clear across the country.
A liver, however, must be transplanted within a few hours.
For some people with HIV, HOPE is a life changer, Castillo-Lugo said, adding that he has another important message for people with HIV: “People who are HIV-positive can be donors and save someone else’s life.”
To be an organ donor, mark your driver’s license or sign an organ donation card. Nothing on the license indicates HIV status. All organs are tested for HIV before transplant.