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Page 2 of 9 Original Research

TABLE 1: Causes of renal dysfunction in people living with human in HIV-infected and -uninfected patients. 12,13 In South Africa,
immunodeficiency virus. HIV infection was previously considered a contraindication
Variable Description
Acute kidney Dehydration secondary to gastroenteritis for both chronic haemodialysis and renal transplantation, but
injury 2,3,4 Sepsis and opportunistic infections (e.g. Mycobacterium this policy has been revised (after 2009). This is in line with
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tuberculosis)
HIV-associated thrombotic microangiopathies (e.g. TTP/HUS) regulations internationally including the 2013 United States
Chronic kidney Glomerular lesions HIV Organ Policy Equity Act. This law also authorised the
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disease 2,3,4 • HIV-associated nephropathy (HIVAN)
• HIV-associated nephropathy with focal glomerulosclerosis use of HIV-infected organs for transplantation in PLWH. In
(HIV-FSGS)
• HIV-immune complex deposition (HIVICD) South Africa, the outcomes in PLWH undergoing kidney
• Other glomerulonephropathies (including amyloidosis,
minimal change disease, immunotactoid nephropathy) transplantation are equivalent to those seen in other studies
Tubulointerstitial disease for both HIV-infected and -uninfected donor pools. Some
• Proximal tubular injury – tenofovir toxicity
• Chronic tubular injury – amphotericin, tenofovir toxicity centres in South Africa have begun utilising organs from HIV-
• Crystal nephropathy – ciprofloxacin, Acyclovir (intravenous) infected deceased donors, with 100% 1-year graft survival. 14
• Interstitial nephritis – infections (hepatitis B), immune
reconstitution inflammatory syndrome following ART.
Comorbid Hypertensive nephrosclerosis The Wits Donald Gordon Kidney Transplant programme is
diseases 2,3,4 Diabetic nephropathy
Autoimmune disease (lupus nephritis) one of the largest national programmes. Listing of PLWH as
Genetic Apolipoprotein-1 (APOL1) genetic variants recipients commenced in Johannesburg in 2014. The current
predisposition 2,3,4
guidelines for eligibility for deceased-donor kidney
TTP, thrombotic thrombocytopenia purpura; HUS, hemolytic uraemic syndrome; ART,
antiretroviral therapy. transplantation in an HIV-infected individual in the
Johannesburg transplant program include stable ART with
Renal replacement therapy (RRT) for patients with ESKD good adherence for the past 6 months, absence of acquired
comprises two modalities – kidney transplantation and immunodeficiency syndrome (AIDS)-defining illnesses,
chronic dialysis therapy, which can be either haemodialysis
or peritoneal dialysis. CD4+ T-cell counts of > 200 cells/µL for 6 months and
undetectable viral load for more than 6 months. 16
Chronic dialysis therapy is expensive for multiple reasons. At
a health system level, the provision of chronic dialysis services The CD4+ T-cell count is an important risk predictor of patients
requires highly trained medical professionals, expensive undergoing transplantation. Patients with absolute CD4+ T-cell
equipment that needs maintenance, high-volume count of < 200 cells/µL are at an increased risk of opportunistic
consumables, water purification systems (for haemodialysis) infections, have a higher post-transplant rejection rate and
and a dedicated space for dialysis that has access to in-hospital present with delayed CD4+ T-cell count recovery after the
services. For the individual with ESKD, chronic dialysis procedure. Although HIV infection is the primary driver of the
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requires regular monitoring of critical indices with blood reduced CD4+ T-cell count in PLWH, other factors may also
tests, expensive pharmacotherapeutics such as parenteral iron impact the peri-transplant immune status of patients including
and erythropoietin and creatinine and ongoing patency of the use of chronic haemodialysis. Previous studies, examining
access for dialysis, either with a peritoneal catheter or with the impact of haemodialysis on leucocyte counts and leucocyte
vascular access for haemodialysis. This adds substantial cost subsets, have been performed in the past on HIV-uninfected
for healthcare providers (whether state or private) and, when cohorts. The findings of these studies are contradictory.
not funded, can be passed on to individuals as ‘out-of-pocket’ Generally, they showed consistently decreased levels of CD3+,
expenses. These dialysis-related expenses occur in addition to CD4+ and CD8+ T cells. However, these measurements were
the costs of treating additional comorbidities such as
hypertension, diabetes and HIV infection. 6 taken at various intervals between haemodialysis and not
immediately post-dialysis. These studies postulated that direct
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Limited haemodialysis slots are available for patients with contact between lymphocytes and dialyser membranes could
ESKD. In South Africa, access to RRT is disparate, with 189 result in activation of lymphocytes with subsequent apoptosis. 11,12
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slots for renal dialysis per million population overall, but only
71.9 per million population available to the public sector. A concern, therefore, exists that chronic haemodialysis could
7
Currently no national policy is available regulating access to reduce CD4+ T-cell count, especially in PLWH, and this
RRT in South Africa. A recent audit conducted in the Western would impact their eligibility for the deceased donor list. The
Cape revealed that, of all the patients receiving dialysis, only aim of this study was to measure immediate and ongoing
10% were people living with HIV (PLWH). In view of these T-cell counts and T-cell subsets to evaluate the immediate
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limitations, kidney transplantation is an attractive option. influence of haemodialysis on the lymphocyte subsets in
Kidney transplantation is a curative therapy that prolongs life PLWH having ESKD receiving chronic haemodialysis.
in patients with ESKD and is more cost-effective even in
complicated cases with high levels of sensitisation. 9,10 Design

Kidney transplantation in PLWH has shown improved This was a cross-sectional study that compared two groups at
overall survival outcomes when compared to PLWH on the same time. The study participants (n = 17) included all
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chronic haemodialysis. Morbidity and mortality data also eligible HIV-infected adults with ESKD receiving chronic
suggest that outcomes after renal transplantation are similar haemodialysis (three sessions a week, each lasting ~4 hours),

http://www.sajhivmed.org.za 212 Open Access