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Transplantação renal e VIH : revisão da literatura e registo de 10 doentes
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Resumo(s)
O vírus da imunodeficiência humana (VIH) é ainda uma questão de saúde importante e os doentes infetados apresentam risco acrescido para desenvolvimento de doença renal crónica. O advento da terapêutica antirretroviral permitiu aumentar a esperança média de vida nesta população e a experiência prévia descrita demonstrou que a transplantação renal (TR) é exequível em doentes selecionados. A sobrevida assemelha-se à dos doentes sem esta infeção, sendo a mortalidade inferior à permanência em diálise, sem aumento da progressão para síndrome da imunodeficiência adquirida (SIDA) ou infeções oportunistas. No entanto, as taxas de rejeição aguda são mais elevadas do que em doentes VIH negativos. Uma possível explicação está relacionada com interações medicamentosas entre a terapêutica imunossupressora e antirretroviral, resultando em exposição alterada à primeira. Neste estudo observacional de coorte retrospetiva foram analisadas as características e evolução dos 9 doentes infetados pelo VIH transplantados no Hospital de Santa Cruz (HSC) entre 2011 e 2017, bem como de uma doente que contraiu VIH após TR, com particular enfoque nos regimes antirretrovirais e imunossupressores e possíveis interações resultantes. Todos os doentes receberam rim de dador cadáver, apresentavam carga viral indetetável e CD4>200 cél/mL previamente à TR. Os regimes antirretrovirais mais utilizados incluíam inibidores da integrase. A maioria dos doentes recebeu terapêutica de manutenção que continha tacrolimus, verificando-se naqueles também sob inibidores da protease uma maior instabilidade dos valores de tacrolimus, com necessidade de acentuadas reduções de dose e espaçamento entre tomas. Na data da última consulta de seguimento, após um tempo mediano de 43 meses, todos os doentes se encontravam vivos e com enxerto funcionante (creatinina 1.02-2.2mg/dL), sem exacerbação da infeção por VIH. Apenas se detetou um episódio de rejeição, número abaixo da média descrita na literatura, tendo sido eficazmente tratado. A experiência no HSC corrobora a viabilidade da transplantação renal em doentes VIH selecionados.
Human immunodeficiency virus (HIV) remains an important health issue and patients infected with this virus are at increased risk of developing chronic kidney disease. With the onset of antiretroviral therapy there was an improvement in this population’s life expectancy and published previous experience showed that kidney transplantation is attainable in selected patients. Survival rates are comparable to HIV-negative patients and mortality is inferior to patients remaining in dialysis. No increase was observed in progression to acquired immune deficiency syndrome (AIDS) or opportunistic infections. Nevertheless, acute rejection rates are higher than in HIV negative patients. One of the possible explanations is related to drug interactions between immunosuppressive medications and antiretroviral therapy, resulting in altered exposure to the immunosuppression. In this observational retrospective cohort study, the characteristics and evolution of the 9 HIV-positive patients transplanted at Hospital de Santa Cruz between 2011 and 2017 were analyzed, as well a patient who was infected with HIV after the kidney transplantation. A particular focus was placed on antiretroviral and immunosuppressive regimens and possible drug interactions. All patients received a kidney from deceased donors. All had undetectable viral load and a CD4 count>200 cel/mL prior to kidney transplantation. The most commonly used antiretroviral regimens included integrase inhibitors. The majority of patients received maintenance immunosuppressive therapy incorporating tacrolimus, and those also taking protease inhibitors experienced a greater instability of tacrolimus levels, requiring marked dose reductions and longer dosing intervals. At the time of the last follow-up appointment, after a median period of 43 months, all patients are alive and with functioning graft (creatinine 1.02-2.2mg/dL), without exacerbation of HIV infection. Only one episode of rejection was detected, a number lower than the described in literature, having been successfully treated. Therefore, the experience at Hospital de Santa Cruz corroborates the feasibility of kidney transplantation in selected HIV patients.
Human immunodeficiency virus (HIV) remains an important health issue and patients infected with this virus are at increased risk of developing chronic kidney disease. With the onset of antiretroviral therapy there was an improvement in this population’s life expectancy and published previous experience showed that kidney transplantation is attainable in selected patients. Survival rates are comparable to HIV-negative patients and mortality is inferior to patients remaining in dialysis. No increase was observed in progression to acquired immune deficiency syndrome (AIDS) or opportunistic infections. Nevertheless, acute rejection rates are higher than in HIV negative patients. One of the possible explanations is related to drug interactions between immunosuppressive medications and antiretroviral therapy, resulting in altered exposure to the immunosuppression. In this observational retrospective cohort study, the characteristics and evolution of the 9 HIV-positive patients transplanted at Hospital de Santa Cruz between 2011 and 2017 were analyzed, as well a patient who was infected with HIV after the kidney transplantation. A particular focus was placed on antiretroviral and immunosuppressive regimens and possible drug interactions. All patients received a kidney from deceased donors. All had undetectable viral load and a CD4 count>200 cel/mL prior to kidney transplantation. The most commonly used antiretroviral regimens included integrase inhibitors. The majority of patients received maintenance immunosuppressive therapy incorporating tacrolimus, and those also taking protease inhibitors experienced a greater instability of tacrolimus levels, requiring marked dose reductions and longer dosing intervals. At the time of the last follow-up appointment, after a median period of 43 months, all patients are alive and with functioning graft (creatinine 1.02-2.2mg/dL), without exacerbation of HIV infection. Only one episode of rejection was detected, a number lower than the described in literature, having been successfully treated. Therefore, the experience at Hospital de Santa Cruz corroborates the feasibility of kidney transplantation in selected HIV patients.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2018
Palavras-chave
VIH Transplantação renal Terapêutica antirretroviral Imunossupressão