Case Study: Positive HIV-1 Status Should Not Preclude Heart Transplant

HIV-1-positive status should not preclude heart transplant (HT) in carefully selected individuals, according to the results of a study published in AIDS Research and Therapy.

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As morbidity and mortality associated with HIV have declined over the past few decades, outcomes have begun to reflect comorbidities common in aging populations. Cardiovascular disease (CVD) has become one of the leading causes of non-HIV related deaths in HIV-positive individuals.

People with HIV are not generally considered candidates for a transplant due to theoretical concerns regarding the impact of immunosuppressant medications following transplant, and the complex drug-drug interactions (DDIs) that come with it. However, evidence from case reports has indicated promising outcomes for patients with HIV who undergo HT.

The investigators reported the long-term follow-up of a patient with HIV who underwent orthotopic HT with special focus on DDIs and long-term outcomes. The patient was a 58-year-old male with HIV-1 infection and a medical history of cardiovascular risk factors such as hypertension and coronary artery disease, among others.

He presented with severe chronic systolic HF due to ischemic cardiomyopathy diagnosed in 2008. He has had cardiac functional decline since November 2014. He underwent impatient evaluation for transplant/left ventricular assist device and was initially stabilized, but was re-hospitalized with further decline.

When the patient was admitted to the hospital for advanced heart failure (HF) in March 2015, his antiretroviral therapy (ART) regimen was modified to remove DDS with the projected post-HT immunosuppressive regimen. The patient underwent orthotopic HT in July 2015, and began an immunosuppressive treatment plan.

The patient remained in good health 76 months after the HT. Shortly after the transplantation, there was a notable improvement in cardiac function. Further, he has not had any AIDS-defining illnesses or opportunistic infections, nor major adverse effects from ART since the HT.

Some post-HT complications emerged over the 76-month follow-up period. At 22-months post-HT, the patient had an abnormal prostate exam, which was the result of adenocarcinoma of the prostate, and a prostatectomy was undergone. He also developed basal cell carcinoma, which was safely stopped 44-months post HT; however, as of November 2021, no other major complications have developed.

Despite the positive results from the case study, the investigators discussed that the paucity of the clinical data should lead to careful evaluation and selection of a HT candidate in the setting of HIV infection. They emphasized consideration of pre-transplant HIV-RNA viral load and CD4 count, the presence of opportunistic infections, and potential for DDs following the initiation of HT therapies.

Regarding DDIs, the investigators observed that protease inhibitors, non-nucleoside reverse transcriptase inhibitors, and cobicistat-boosted regimens have the most clinically relevant and significant drug interactions with immunosuppression medications. The patient is now on an ART regimen free of protease inhibitors, pharmacokinetic boosters, and non-nucleoside reverse transcriptase inhibitors, which has low potential to interact with his immunosuppression regimen.

The study authors observed a clinical outcome in the patient that was comparable to the general population with HIV, as well as those receiving HT. They noted that no opportunistic infections developed in the setting of HT immunosuppressive therapy, and his underlying HIV and concomitant ART did not appear to negatively impact early or intermediate-term graft function.

“Even though it is less frequently performed and reported than liver and kidney transplantation, HT in this population appears to be successful in carefully chosen and well-managed patients with virologic suppression in whom DDIs have been mitigated,” the study investigators concluded.

Reference

Almangour TA, Skersick PT, Corbett A et al. Heart transplantation and human immunodeficiency virus–navigating drug-drug interactions: a case report. AIDS Res Ther. 2023;(20)55. doi:10.1186/s12981-023-00551-x