Renal Transplantation for HIV and Obese Patients

Dr. Jim Wood

The field of renal transplantation has been both a victim and a beneficiary of improved survival in patients with chronic medical diseases. Not more than 10 years ago, HIV and significant obesity (a body mass index above 35) were considered absolute contraindications to receiving a kidney transplant. Today these medical issues are part of the changing landscape of renal transplantation.

HIV

An increasing number of transplant centers perform renal transplants on HIV-positive patients. Several protocols exist in which potential drug interactions between Highly Active Anti-Retroviral Therapy (HAART) and immunosuppressive agents are considered. That said, a transplant in an HIV-positive patient should not be undertaken without a thorough transplant and infectious disease evaluation. First, the patient’s HIV RNA level should be suppressed to an undetectable level and the patient should be free of any opportunistic infection. Second, the patient should be on a stable HAART regimen and an infectious disease specialist comfortable with managing HAART therapy in the setting of obligatory immunosuppression should followed the patient closely.

Obesity

As Americans become more obese, so have patients with end-stage renal disease. Several studies have recently demonstrated the benefits of kidney transplantation in patients with body mass indexes (BMIs) over 35. Transplant teams generally encourage these subjects to lose weight to improve wound healing and reduce any postoperative complications, but today only a BMI above 40 is considered an absolute contraindication to transplantation. In most cases, a BMI between 35 and 40 should not be a contraindication. However the BMI must be considered in the context of patient motivation, self discipline with treatment and overall medical well being.

Case reviewers will increasingly be asked to assess medical necessity of kidney transplantation in a greater number of marginal transplant candidates, including some with HIV or obesity. While these and other medical issues are no longer absolute contraindications to transplantation, we must ensure that these patients undergo a thorough evaluation prior to deeming a kidney transplant as medically necessary. Case managers should look for such evaluation in the patient’s records when evaluating the medical necessity of the treatment.