United Press International - October 15, 2001
Ed Susman, UPI Science News

To receive the organs, the patients infected with human immunodeficiency virus or HIV must also receive cyclosporine -- a drug that suppresses immune function so the body does not reject the organ.

"Frankly, a lot of us thought that giving cyclosporine to these patients would be almost immediately fatal," said Dr. Lynda Frassetto, associate clinical professor of medicine at the University of California, San Francisco.

Frassetto said eight of her first nine transplant patients have survived, one for as long as 18 months. The patient who died, she told United Press International, was infected through blood products used to help him fight off childhood leukemia. The blood products, she said, infected the then 2-year-old with HIV and hepatitis C. He received two liver transplants, but died 15 months later of advanced hepatitis -- not HIV or organ rejection.

Three patients, including a child who underwent transplant surgery the first time at age 15, received livers. Six patients, including the only woman in the group, received kidneys. Aside from the teenager, the adults who received organs ranged in age from 38 to 53 at the time the operations were done.

In a presentation at the congress, co-sponsored by the Washington-based American Society of Nephrology and the Amsterdam-based International Society of Nephrology, Frassetto said she had to overcome two major hurdles to even perform the pilot study:

-- Would giving immune suppressing agents worsen the condition of immune-challenged HIV patients?

-- Was it ethical to take scarce resources -- donated organs that thousands of people need -- and transplant them into HIV-infected individuals who may have a shortened life span due to their disease?

"Those were among the questions we had to answer to our institutional review board before we could begin the project," Frassetto said. "The IRB had questions about everything."

However, in mid-2000, she got approval to begin transplanting selected patients. They were HIV-infected individuals who had their viral loads under control, meaning they were taking antiretroviral drugs as prescribed. They were treated for all other diseases and conditions before undergoing transplant, and were either next in line on a transplant list, received an organ from a family donor or were willing to accept organs that were rejected from other institutions -- often because the donor was elderly.

As to the first question, whether cyclosporine would make matters worse, Frassetto said researchers had a hint that perhaps it would not be so bad.

"In test-tube studies," Frassetto told UPI, "we observed that cyclosporine appeared to suppress HIV replication. But what happens in a culture dish doesn't necessarily happen in humans. However, in our patients receiving cyclosporine, their levels of CD4-positive cells have increased -- sometimes markedly."

CD4-positive cells are blood cells that are markers of immune competence. The larger the number, the easier it is for patients to fight off the hallmark infections of AIDS/HIV progressions.

"Fifteen years ago, having HIV infection was an absolute exclusion for receiving a transplant," said Dr. Solomon Smith, a nephrologist and AIDS specialist affiliated with the Veterans Affairs Hospital in Columbia, S.C. "But now, with treatments, we have extended the life expectancy of AIDS patients so that these patients with liver and kidney failure can benefit from these transplants."

However, Smith told UPI doctors have to carefully select patients who are most likely to benefit from the operations before doing the organ surgery.

Frassetto said the procedure is still too new to be routinely advocated.

"Any transplant into an HIV-infected patient should be done as part of an experimental protocol," she said. "This is still a very complicated procedure and requires the help of a lot of specialists in surgery, transplantation, AIDS treatment as well as nephrology."

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