Induction Immunosuppression and Clinical Outcomes in Kidney Transplant Recipients Infected With Human Immunodeficiency Virus

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There is an increased risk of acute rejection (AR) in human immunodeficiency virus–positive (HIV+) kidney transplant (KT) recipients. Induction immunosuppression is standard of care for those at high risk of AR; however, use in HIV+ patients is controversial, given fears of increased infection rates. We sought to compare clinical outcomes between HIV+ KT recipients who were treated with (i) anti–thymocyte globulin (ATG), (ii) IL-2 receptor blocker, and (iii) no induction. We studied 830 HIV+ KT recipients between 2000 and 2014, as captured in the Scientific Registry of Transplant Recipients, and compared rates of delayed graft function (DGF), AR, graft loss and death. Infections and hospitalizations were ascertained by International Classification of Diseases, Ninth Revision codes in a subset of 308 patients with Medicare. Compared with no induction, neither induction agent was associated with an increased risk of infection (weighted hazard ratio [wHR] 0.80, 95% confidence interval [CI] 0.55–1.18). HIV+ recipients who received induction spent fewer days in the hospital (weighted relative risk [wRR] 0.70, 95% CI 0.52–0.95), had lower rates of DGF (wRR 0.66, 95% CI 0.51–0.84), less graft loss (wHR 0.47, 95% CI 0.24–0.89) and a trend toward lower mortality (wHR 0.60, 95% CI 0.24–1.28). Those who received induction with ATG had lower rates of AR (wRR 0.59, 95% CI 0.35–0.99). Induction in HIV+ KT recipients was not associated with increased infections; in fact, those receiving ATG, the most potent agent, had the lowest rates. In light of the high risk of AR in this population, induction therapy should be strongly considered.

Key words

basic (laboratory) research/science
clinical research/practice
cellular biology
immunosuppression/immune modulation
immune regulation
tolerance
metabolism/metabolite

Abbreviations

anti-IL2R
IL-2 receptor blocker
AR
acute rejection
ATG
anti–thymocyte globulin
CI
confidence interval
CIT
cold ischemic time
CMS
Centers for Medicare and Medicaid Services
CMV
cytomegalovirus
DCD
donation after cardiac death
DGF
delayed graft function
ECD
expanded criteria donor
ESRD
end-stage renal disease
HBsAg
hepatitis B surface antigen
HCV
hepatitis C virus
HIV+
human immunodeficiency virus positive
HIV–
human immunodeficiency virus uninfected
ICD-9
International Classification of Diseases, Ninth Revision
IPTW
inverse probability of treatment weight
KT
kidney transplant
LOS
length of stay
NIH
National Institutes of Health
OPTN
Organ Procurement and Transplantation Network
PRA
panel reactive antibody
SD
standard deviation
SRTR
Scientific Registry of Transplant Recipients
UTI
urinary tract infection
wHR
weighted hazard ratio
wRR
weighted relative risk

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