Response to: Regarding “HIV protease inhibitors and mortality following kidney transplantation”
Year: 2018
Type: letter
Abstract: We thank Dr Sullivan for his thoughtful commentary on our recent analysis of protease inhibitors (PIs) and kidney transplant outcomes among HIV-infected kidney transplant recipients.1Sullivan T. HIV protease inhibitors and mortality following kidney transplantation [published online ahead of print January 9, 2018]. Am J Transplant. https://doi.org/10.1111/ajt.14655Google Scholar,2Sawinski D Shelton BA Mehta S et al.Impact of protease inhibitor-based anti-retroviral therapy on outcomes for HIV+ kidney transplant recipients.Am J Transplant. 2017; 17: 3114-3122Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar He suggests that posttransplantation PI use may be a marker of more-advanced HIV infection, driven by genotypic evidence of HIV resistance to multiple classes of antiretroviral therapies. Thus, with a complicated HIV treatment history, the increased association of PIs with posttransplantation mortality may actually be capturing the risk of death associated with antiretroviral resistance, rather than an impact of PIs themselves on outcomes. We agree with the author that this is possible, but, as mentioned in our limitations, we did not have access to patients’ HIV treatment histories, HIV viral loads, CD4 counts, or resistance data and cannot assess to what extent those HIV-specific risk factors may affect our conclusions. Despite the limitations imposed by lack of HIV-specific data, we believe our findings have important implications for the management of HIV-infected kidney transplant candidates. Despite robust evidence of drug–drug interactions between PIs and calcineurin inhibitors, many patients are still regularly referred for transplant evaluation while maintained on PI-based regimens, even in the absence of antiretroviral resistance.3Azar MM Malinis MF Moss J Formica RN Villanueva MS Integrase strand transferase inhibitors: the preferred antiretroviral regimen in HIV-positive renal transplantation.Int J STD AIDS. 2017; 28: 447-458Crossref PubMed Scopus (18) Google Scholar,4Rosa R Suarez JF Lorio MA et al.Impact of antiretroviral therapy on clinical outcomes in HIV (+) kidney transplant recipients: review of 58 cases.F1000Res. 2016; 5: 2893Crossref PubMed Scopus (17) Google Scholar We understand reluctance to alter patient regimens given provider concerns for loss of control of HIV infection and patient concerns about new and/or additional side effects, but we believe our data further elucidate the association between PIs and adverse outcomes among HIV-positive kidney transplant recipients. Moreover, we feel strongly that these data support the routine transition of HIV-positive transplant candidates to a non-PI regimen whenever medically feasible and are hopeful these data will assist with the development of evidence-based protocols for HIV-positive kidney transplantation. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.
DOI: 10.1111/ajt.14688
Authors: B.A. Shelton, D. Sawinski, J.E. Locke
Language: English
Subfield: Transplantation
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $4,300
OpenAlex ID: W2793558853