|Year : 2022 | Volume
| Issue : 4 | Page : 455-457
A case report of ABO-incompatible kidney transplant in human immunodeficiency virus-positive patient coinfected with both hepatitis B and hepatitis C viruses: A case report
Raka Kaushal1, Avinash Srivastava2, Kulwant Singh1
1 Department of Nephrology, IVY Hospital, Mohali, Punjab, India
2 Department of Urology and Renal Transplant, IVY Hospital, Mohali, Punjab, India
|Date of Submission||05-Feb-2022|
|Date of Acceptance||18-Sep-2022|
|Date of Web Publication||30-Dec-2022|
Dr. Kulwant Singh
Department of Nephrology, IVY Hospital, Sector 71, Mohali - 160 071, Punjab
Source of Support: None, Conflict of Interest: None
Individuals with human immunodeficiency virus (HIV) are at increased risk for end-stage kidney disease (ESKD). Kidney transplantation is the best treatment for HIV-positive ESKD patients. There are many challenges such as interactions between antiretroviral drugs and immunosuppressants, coinfection with hepatitis B (HBV) or/and C (HCV) viruses, and a higher risk of posttransplant infections and malignancies. We should not defer HIV-positive kidney transplants perceiving these medical complexities, instead employ a multidisciplinary approach to achieve successful transplantation. For HIV-positive ESKD patients, ABO-incompatible (ABOi) kidney transplantation and considering HIV-positive kidney donors are successful strategies for increasing the donor pool. We report a case of an HIV-positive ESKD patient who had coinfection with both HBV and HCV viruses and successfully underwent an ABOi live-related kidney transplant.
Keywords: ABO-incompatible kidney transplant, double filtration plasmapheresis, hepatitis B virus, hepatitis C virus, human immunodeficiency virus-positive, posttransplant infections
|How to cite this article:|
Kaushal R, Srivastava A, Singh K. A case report of ABO-incompatible kidney transplant in human immunodeficiency virus-positive patient coinfected with both hepatitis B and hepatitis C viruses: A case report. Indian J Transplant 2022;16:455-7
|How to cite this URL:|
Kaushal R, Srivastava A, Singh K. A case report of ABO-incompatible kidney transplant in human immunodeficiency virus-positive patient coinfected with both hepatitis B and hepatitis C viruses: A case report. Indian J Transplant [serial online] 2022 [cited 2023 Feb 3];16:455-7. Available from: https://www.ijtonline.in/text.asp?2022/16/4/455/364616
| Introduction|| |
End-stage kidney disease (ESKD) patients with human immunodeficiency virus (HIV) positive status face significant barriers in accessing renal replacement therapies (both dialysis and kidney transplantation) in most developing countries. We are presenting a case of a 47-year-old-male who became HIV positive within 4 months of starting hemodialysis treatment. He was facing great difficulties as his nearby centers were not performing dialysis for HIV-positive patients, and he was the sole breadwinner for the family. Hence, the only way forward for him was to undergo renal transplantation. Apart from being coinfected with both hepatitis C (HCV) and hepatitis B (HBV) viruses, he had only one eligible donor in the family that too of a different blood group. HIV-positive patients have been successfully transplanted for the last 15 years and the donor pool has successfully been expanded by employing various strategies that include ABO-incompatible (ABOi) kidney transplant and considering HIV-positive donors. To our knowledge, this is the first reported case from India of an HIV-positive ESKD patient who was coinfected with HBV and HCV viruses and underwent an ABOi living-related donor kidney transplant.
| Case Report|| |
We present a case of a 47-year-old male who was diagnosed chronic kidney disease in December 2018 and gradually progressed to ESKD requiring dialysis in October 2020. He had a history of hypertension for 6 years and an ultrasound showed bilateral small kidneys. He was hepatitis B surface antigen positive before initiation of hemodialysis. Hepatitis B e-antigen and HBV-DNA quantitative were negative and liver enzymes were normal, considering chronic/inactive carrier but with comorbidities, family history of HBV-related hepatocellular carcinoma in father and liver stiffness measurement of 7 kPa by FibroScan, he was started on entecavir 0.5 mg once per week. In January 2021, he was diagnosed HIV positive on routine evaluation, which was further confirmed with ELISA and western blot. He denied any history of blood transfusions. His initial viral load (VL) was 1575 copies/ml, and his CD4 count was 334 cells/mm3. He was started on highly active antiretroviral therapy (HAART) – zidovudine (300 mg PO qDay), lamivudine (50 mg PO qDay), and nevirapine (200 mg PO q12 h). After 2 months of treatment, his CD4 count increased to 402 cells/mm3.
He had to travel a long distance for his routine dialysis as centers near to his home were not performing dialysis for HIV patients. As he was the sole breadwinner for his family, the transplant was the only way forward. He had only one eligible donor in the family (his wife) but the blood group was not compatible. Initially, he tried for swap – paired kidney transplant but the flow cytometric crossmatch of the other pair came positive. His blood group was B positive and his wife's blood group was AB positive. During this period, he was also diagnosed positive for HCV, HCV RNA quantitative was 1732 IU/ml, and was started on sofosbuvir 400 mg/velpatasvir 100 mg PO qDay.
He was evaluated for ABOi renal transplantation. His anti-A immunoglobulin (Ig), immunoglobulin G, and immunoglobulin M titers were 1:32 (by gel agglutination column method). His HAART regimen was modified to abacavir (600 mg PO qDay), lamivudine (50 mg PO qDay), and dolutegravir (50 mg PO qDay) considering future interactions with calcineurin inhibitors (CNIs). His VL was repeated after 6 weeks which was undetectable and CD4 counts were 464 cells/mm3. His HCV RNA polymerase chain reaction (PCR) was also undetectable after 6 weeks of sofosbuvir/velpatasvir. His Epstein–Barr virus (EBV) and cytomegalovirus (CMV) serology before transplant were negative.
As per our protocol, he was given an injection of rituximab (anti-CD 20) 500 mg 3 weeks before transplant, and tacrolimus and mycophenolate mofetil (MMF) was started 1 week before transplant. He underwent one session of double-filtration plasmapheresis with Evaflux column and one session of therapeutic plasma exchange along with intravenous Ig, and was taken up for transplant after anti-A titers were < 1:8. Induction was not given to decrease the risk of over immunosuppression. His postoperative period was uneventful. Anti-A titers remained <1:4. He was discharged with stable graft function (serum creatinine: 0.9 mg/dl) on triple immunosuppressants along with his HAART regimen (lamivudine was increased to 300 mg PO qDay). He was also started on co-trimoxazole prophylaxis; valganciclovir was not added considering induction therapy was not used and CD4 counts were above 400 cells/mm3.
Early posttransplant period – Issues and learnings
After 3 weeks of transplant, he presented with abdominal discomfort including loose stools for which his antiproliferative agent MMF was changed to azathioprine (75 mg). As he was not responding to conservative management and graft function was deteriorating, so he was evaluated in detail along with a gastroenterologist. Workup for diarrhea revealed stool test positive for cryptosporidium oocysts and CMV-PCR in whole blood was also positive. Colonoscopy was not done. He had no evidence of CMV-related involvement of any other organs of the body. He was managed initially with nitazoxanide and intravenous ganciclovir which was later changed to oral valganciclovir. He improved symptomatically and renal functions also showed improving trends. Postdiarrhea his tacrolimus levels remained on the higher side (14.68 ng/dl), so tacrolimus was tapered down and steroids were up titrated. In view of persistent graft dysfunction, graft biopsy was done to rule out any rejection, CNI toxicity, or CMV-related graft involvement. Histopathology showed changes of acute tubular necrosis which was managed conservatively with hydration and tacrolimus levels were targeted slightly in the lower range between 6 and 8 ng/ml. He is now >6 months posttransplant with stable graft function on triple immunosuppression (tacrolimus, azathioprine, and prednisolone) along with HAART, co-trimoxazole, and valganciclovir prophylaxis. His last CD4 counts were 704 cells/mm3 and VL was undetectable.
| Discussion|| |
HIV infection is now no longer considered an absolute contraindication for kidney transplantation. Kidney transplantation is the best method of renal replacement therapy, still individuals with HIV face multiple barriers in accessing both dialysis and kidney transplantation, especially in developing countries.,
Apart from general medical and psychosocial fitness, HIV-positive ESKD patients must have an undetectable VL, CD4 count ≥200 cells/mm3, and should be on a stable antiretroviral therapy regimen. We transplanted early at 10 weeks of switching to an integrase inhibitor-based regimen for the reasons mentioned above in the introduction. Integrase inhibitor-based HAART is preferred over protease inhibitor (PI). PIs inhibit the CYP3A4 pathway thus increases levels of CNIs. This leads to significant CNI dose reductions, often irregular dosing schedules, and lower area under the curve of CNI exposure at similar trough levels which further leads to the increased rates of acute rejection.,
Induction agent was not used in this patient to minimize the risk of over immunosuppression. However, the HIV-transplant recipient multisite trial demonstrated that, despite relative immunodeficiency, HIV-positive recipients are at increased risk of acute rejection. Induction with rabbit anti-thymocyte globulin has been associated with a 61% reduction in acute rejection episodes and also improved death-censored graft loss.
All these patients should be evaluated in detail for active opportunistic infections. They must undergo nucleic acid test (NAT)/PCR for HCV, HBV, and CMV as serology-based antibody testing can be falsely negative. Evaluation for latent tuberculosis, EBV serology, and stool examination for protozoal infections should also be part of the initial workup. These patients should have their CD4 count and HIV-VL checked at every 2–3-month interval during the posttransplant period.
Consensus guidelines suggest at least 1 year of pneumocystis jirovecii pneumonia prophylaxis with co-trimoxazole, but some centers continue it for even lifelong. As mentioned earlier, postoperative this patient was discharged on co-trimoxazole prophylaxis only; valganciclovir was not added for the reasons mentioned above. CMV prophylaxis approaches vary, with some centers employing the same approach as in patients who are HIV-negative as per KDIGO guidelines, whereas others use high-dose valganciclovir (900 mg daily) for 3–6 months., We avoided valganciclovir initially considering no induction agent has been used but later learned that we should have evaluated him in detail with CMV-PCR before transplant.
| Conclusions|| |
ABOi kidney transplant definitely increases the donor pool for HIV-positive ESKD patients. Perceived medical complexity should not be the barrier, instead, we shall use a multidisciplinary approach to give successful results. Integrase inhibitor-based HAART has less interactions with immunosuppressants. NAT/PCR for HCV, HBV, and CMV should be preferred over serology-based antibody testing as later can be falsely negative. Detailed evaluation for latent tuberculosis, EBV serology, stool examination, and occult malignancies should be part of pretransplant workup, and prophylaxis with both co-trimoxazole and valganciclovir is advisable.
Declaration of patient consent
The authors certify that the patient consent has been taken for participation in the study and for publication of clinical details and images. The patient understands that the names and initials would not be published, and all standard protocols will be followed to conceal the identity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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