Under the HOPE Act, living HIV-positive organ donors are allowed; however, this practice is not well-accepted ethically due to increased risk for the donor and the potential for HIV infection in the recipient. In 2018, surgeons in South Africa reported on the first case involving an HIV-positive living donor and an HIV-negative recipient.1

A 7-month-old child with biliary atresia had end-stage liver disease. The child was born to HIV-positive parents. Her mother was incidentally diagnosed with HIV at the age of 27 and began antiretroviral therapy (ART) 4 months after diagnosis. After pregnancy, the newborn patient received daily nevirapine prophylaxis for 6 weeks.

After delivery, the child was HIV-negative and was exclusively breast-fed. Because of her poor health, the child was referred to Wits Donald Gordon Medical Centre (WDGMC) in Johannesburg, South Africa, for further care and management. The WDGMC program provides pediatric liver transplants from both cadaver and living donors. The inclusion of living donors was approved in 2013, 8 years after the start of the program, in response to the shortage of cadaver organs. The average wait time for liver transplantation is 49 days at WDGMC.1


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According to the authors of the study, there is an increased chance of successful liver transplantation in related living donors.2,3 Despite expansion of the donor pool, there had not been a case of living donor liver transplant from an HIV-positive donor to HIV-negative recipient.

This child’s case was practically urgent because she was on the liver transplant waitlist for 181 days with life-threatening hematemesis secondary to variceal bleeding. This resulted in intensive care unit admission that involved intubation and ventilation. The child’s hospital stay was further complicated by Klebsiella pneumoniae infection. The patient had a critical need due to her rapid decline in health.

Her mother persistently requested to be a living donor. With careful consideration, the program requested institutional review board approval to perform the liver transplant per guidelines requiring that her mother meet donor criteria: CD4 T-cell count >200 cells/μL, no active tuberculosis infection, no opportunistic infections, and viral suppression for a least 6 months.

The patient received a liver transplant at 13 months of age. A left lateral segment hepatectomy was performed on her mother. Preoperative immunosuppression management for the recipient consisted of raltegravir/lamivudine/abacavir the night before transplant. The donor’s ART regimen was unchanged. Intraoperative immunosuppression management of 100 mg of methylprednisolone was given to the child.

Postoperative care of the recipient was complicated by pneumonia that was treated with antibiotics. The child was given standard prophylaxis for pneumocystis pneumonia and cytomegalovirus. For 6 months, she received tacrolimus and a corticosteroid taper. HIV status was assessed and showed neither seroconversion nor HIV-1 RNA detection. Post-transplant laboratory results at 225 days also revealed no evidence of HIV-1 DNA. The patient remains on tacrolimus and ART and will receive ART for at least 2 years.

Eudiah Ochieng, PA-C, is a graduate of Augusta University. Lisa Daitch, MPA, PA-C, is an associate professor at Augusta University.

References

1. Botha J, Conradie F, Etheredge H, et al. Living donor liver transplant from an HIV-positive mother to her HIV-negative child: opening up new therapeutic options. AIDS. 2018;32(16):F13-F19.

2. Botha J, Fabian J, Etheredge H, Conradie F, Tiemessen CT. HIV and solid organ transplantation: where are we now. Curr HIV/AIDS Rep. 2019;16(5):404-413.

3. Miro JM, Grossi PA, Durand CM. Challenges in solid organ transplantation in people living with HIV. Intensive Care Med. 2019;45(3):398-400.