| July 25, 2002
Barriers to Organ Transplantation
for HIV-Infected Patients Unethical
Research at University of Pennsylvania School of Medicine
and Michigan Veterans Affairs Medical Center suggests
HIV-positive patients do well after transplantation
PA) -- A paper in the July 25th, 2002, issue of the
New England Journal of Medicine by researchers
at the University of Pennsylvania School of Medicine
and the Michigan Veterans Affairs Medical Center argues
that there are strong ethical reasons to remove barriers
to organ transplantation for HIV-infected patients who
Scott D. Halpern, MSCE, and Arthur L. Caplan,
PhD, of the University of Pennsylvania School of
Medicine and Peter A. Ubel, MD, of the Veterans
Affairs - Ann Arbor Healthcare System, Ann Arbor, MI,
found, in a review of the limited available evidence,
that HIV-positive patients who had received organ transplants
were doing "remarkably well." They argue that
this refutes the common notions that transplantation
in the setting of HIV is unsafe, and that the HIV virus
substantially limits the benefit patients could obtain
from organ transplantation.
Halpern, an MD/PhD student in Penn's School of Medicine,
a fellowin Epidemiology and Biostatistics and lead author
of the paper, says that while there have only been three
or four published cases of patients who received organ
transplants since the advent of highly active, combination
therapy "all of [these patients] have done remarkably
well, and their outcomes were unaffected by HIV disease."
"Right now, most transplantation centers are concerned
that transplantation might harm HIV patients, and that
scarce organs should not be allocated to patients with
poor prognoses, so there's a safety concern as well
as an efficacy concern," says Halpern. "We
believe that the extent of the HIV disease is simply
another chronic illness that must be considered in determining
candidacy for organ transplantation, and that it is
discriminatory to provide organs to patients with diabetes
or hepatitis C infection, for example, who are known
to have worse outcomes after transplantation, but not
to provide organs to HIV positive patients in whom healthcare
professionals merely suspect a poorer outcome,"
The authors argue that while concerns about transplantation
in HIV- positive patients may have been well founded
in the past, the ability of new medicines to keep the
virus in check has enabled patients
to live comfortably several years after receiving new
The researchers also argue that there is no validity
to fears that drugs given to organ transplant recipients
to prevent the body's immune system from rejecting the
new organ would accelerate the progression of HIV, which
also attacks the body's immune system.
"What does happen is that by giving antiretroviral
drugs, what you do is decrease the metabolism of the
anti-immune drugs, but that can be controlled by adjusting
doses of the anti-immune drugs; there are a lot of drugs
that [transplant] patients need that affect the dosage
of the anti-immune drugs, and anti virals are just another
class of drugs that need to be considered and monitored
in transplant recipients."
"With this study we spoke with several transplant
surgeons across the country who have limited experience
with doing this . . . and they corroborated the evidence
that's been published with their own clinical impressions,
that their patients are doing well," Halpern added.
Halpern says physicians at the Hospital of the University
of Pennsylvania provided a liver transplant to a patient
with HIV, and that patient continues to do well nearly
five years later.
The researchers also make clear that while there is
no accepted standard for denying an HIV patient an organ
transplant, there is also no written procedure or standard
for encouraging organ transplants for HIV patients.
"It's just not common practice," says Halpern.
"The governing body of organ donation, the United
Network for Organ Sharing, actually says that asymptomatic
HIV-positive patients should not, in actuality, be ruled
out from receiving an organ, but it doesn't make any
positive recommendation that HIV patients should be
considered like other patients.
"They simply say it is not an exclusion criterion,
and the main reasons that HIV patients continue to be
denied organs stem from concerns of transplant physicians,
nurses, and also very prominent third party payers who
generally have refused to reimburse for transplantation
in HIV-positive patients," says Halpern.
The researchers also said that in the few HIV-positive
patients who have received organs so far, their organ
disease was generally not due to the HIV itself. However,
it is also possible that HIV itself could cause liver,
kidney, or heart disease requiring transplantation.
Almost all transplants in HIV-positive patients to date
have involved livers and kidneys.