Miami Herald - Friday, August 30, 2002
Daniela Lamas, dlamas@herald.com

As stronger therapies keep the virus in check, however, about a dozen transplant centers nationwide -- including Miami's Jackson Memorial Hospital -- are now performing the controversial procedure.

And with careful management of the tricky interaction between anti-rejection and anti-HIV drugs, these transplants can work just as well as they do in people without HIV, cautiously optimistic researchers reported Thursday at the International Congress of the Transplantation Society in Hollywood.

"Until now, these patients were routinely denied," said Dr. Anil Kumar, chief surgeon of the renal transplantation center at Hahnemann University Hospital in Philadelphia, where 20 HIV-positive patients have received kidneys.

"These are sick people. There's no reason we should discriminate against them," said Dr. Andreas Tzakis, director of liver and gastrointestinal transplants at Jackson.

ANTI-HIV THERAPIES

The researchers said these transplants would not be successful without "highly active retroviral therapies" (HAART), drug cocktails that increase life span and decrease HIV-related complications.

With the virus under control, many of these patients are now dying from liver or kidney failure.

This raises the question of whether these organs can be transplanted.

Following a transplant, patients must receive high doses of immuno-suppressant drugs.

Physicians had initially feared that giving the drugs to HIV-positive people, whose immune systems are weakened, would accelerate their disease.

But that hasn't happened to the six HIV-positive patients at Jackson who have received liver transplants in the past 3 years. University of Miami doctors recently co-wrote a paper with the University of Pittsburgh, reporting that 14 of the 16 HIV-positive patients who received liver transplants at their two centers survived, said Dr. John Fung, chief of transplant surgery at Pittsburgh.

DELICATE OPERATION

Although the drugs that suppress the immune system do cause T-cell counts to drop, the strong, continuous fusillade of anti-HIV drugs prevents the virus from replicating, said Dr. Dushyantha Jayaweera, an infectious disease specialist at Jackson.

It's a delicate operation that needs an interdisciplinary approach, he said.

Each patient needs a surgeon, an HIV doctor and a doctor who understands the interaction between medicines.

"There is clearly no magic thing about the drugs we pick," Jayaweera said.

"Whenever there is a problem, rather than blaming it on rejection, we play with things and find the solution as a group. As a result, the patients do well."

A LAST RESORT

An HIV-positive Miamian who declined to give her name said she received a liver transplant at Jackson last summer after physicians elsewhere had told her she had no choice but to "go home to die."

The woman was infected with HIV and hepatitis C through a transfusion in the mid-1980s.

Although hepatitis C generally takes 30 to 40 years to destroy a liver, it acts faster in patients with HIV, Jayaweera said.

"I waited until I was very sick, dying, because I didn't think there was any hope of getting a liver," said the patient, who now takes both anti-rejection and anti-HIV drugs. "Now I feel normal.

She said physicians should be more aware that these operations are an option.

"It shouldn't be any different than if you have a heart problem, or if you're old, or if you have diabetes," she said.

To combat the continued problem of organ shortage, some HIV-positive patients are offered organs that might not otherwise be used -- for instance, high-risk donors, Tzakis said.

Otherwise, these patients can choose to remain in the general organ pool.

INSURANCE

But he said physicians would not accept HIV-positive people as donors, since they could inadvertently transplant a different strand of the virus that could make the patients sicker.

Beyond shortages, the researchers agreed that a main barrier for patients is insurance companies that deem the operation "experimental" and won't pay.

Dr. Guy Neff, a member of the Jackson team that performs transplants in HIV-positive patients, said he was recently in court for a patient who had been denied insurance coverage for a liver transplant. He said the patient won the case and is now awaiting a donor organ.
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