Lung Transplantation in Human Immunodeficiency Virus (HIV): Expanding the Horizons

Abstract

INTRODUCTION: One million people have HIV in the United States; approximately 56,000 new cases of HIV are diagnosed every year. Patients with HIV infection have a higher incidence of pulmonary complications including pulmonary hypertension and pulmonary fibrosis when compared to non-HIV infected patients. Lung transplantation is a relative contraindication in HIV infected patients with end stage lung disease, mainly due to insufficient knowledge about the interactions between immunosuppressive medications and highly active antiretroviral therapy (HAART). However, transplantation of other solid organs such as kidney, liver, and heart, have been performed successfully in HIV patients 1. We present the first case of an HIV-positive patient with idiopathic pulmonary fibrosis (IPF) who underwent successful double lung transplant (DLTx) in USA CASE PRESENTATION: A 65-year-old male with HIV and IPF with secondary pulmonary hypertension was referred for lung transplantation. He was diagnosed with HIV in 2001 and on presentation had a CD4 count of 450/uL and a nondetectable HIV viral load on HAART. His HIV regimen included emtricitabine, tenofovir and atazanavir. The patient underwent DLTx. He was extubated 6 days post-operatively. His initial immunosuppressive medications included tacrolimus, mycophenolate and prednisone, and his prophylactic regimen included valganciclovir, voriconazole, and sulfamethoxazole and trimethoprim. The patient was re-started on his previous HAART therapy 5 days after the transplant. No proton pump inhibitors (PPI) were used because of their interactions with HAART therapy. The patient had no post-operative complications and he was discharged home 17 days after his surgery. Currently, 12 months post-transplant, his CD4 count is 540/uL, and HIV viral load remains non-detectable. He has continued on the same HAART and immunosuppressive medications. Furthermore, the patient has not developed any opportunistic infections and has not been hospitalized after surgery. Routine lung biopsies performed every three months post-tranpslant have shown no evidence of rejection. DISCUSSION: Transplant in HIV infected patients has been successfully performed in other solid organs such as liver, kidney and heart with no major adverse outcomes 1. Lung transplantation in HIV infected patients is still considered as a relative contraindication because of the increase risk of infectious complications and the interactions between HAART and immunosuppressive therapy. Our patient received standard prophylaxis protocol per our institution and did not develop any opportunistic infections. The interactions between the HAART and the immunosuppressive therapy are challenging but can be managed by a multidisciplinary approach. The main interaction is the effect of protease inhibitors (PI) on calcineurin inhibitor levels. Medications such as PPI also interact with HAART altering their absorption. Successful lung transplantation and uneventful follow up of our patient shows that transplantation could be a viable option in HIV infected patients with end stage lung disease. CONCLUSIONS: In the era of HAART therapy, lung transplantation can successfully be performed with good outcomes in the HIV population, as seen in our patient. To our knowledge, this is the first reported case of an HIV infected patient undergoing lung transplantation in the USA 2. HIV-positive patients receiving lung transplants present a unique challenge because of interactions between calcineurin inhibitors and protease inhibitors 3. In our experience HIV disease did not increase the incidence of opportunistic infections and did not have any adverse outcome on allograft function. Lung transplantation could be a reasonable treatment option in well-controlled HIV disease.