Renal transplantation in HIV-positive and HIV-negative patients with advanced stages of kidney disease: equity in transplantation

Background — HIV-infected patients are at a greater risk of end-stage kidney disease (ESKD) than the general population. Considering the risk of death after ESKD, access of HIV-infected patients to renal transplantation is critically important.

Methods — We included all adult patients on chronic dialysis in Ontario, Canada, between April 1, 2007, and December 31, 2020. We determined the probability of kidney transplantation with competing risk of death over time since the initiation of dialysis by calculating the adjusted subdistribution hazard ratios [sdHR, 95% confidence interval (CI)]. We also compared long-term renal allograft and post-transplant mortality outcomes between HIV-negative and HIV-positive patients.

Results — Of 40,686 patients (median age 68 years; interquartile range, 57-77; 38.4% women), 173 were HIV-positive, and 40,513 were HIV-negative. The incidence of kidney transplantation in HIV-negative and HIV-positive patients was 40.5 (CI 95%: 39.4 to 41.6)/1000 person-year and 35.0 (CI 95%: 22.8 to 53.7)/1000 person-years, respectively (p = 0.51). Considering the competing risk of death, HIV-positive patients had a significantly lower chance of receiving kidney transplants than HIV-negative patients [sdHR: 0.46 (CI 95%: 0.30-0.70)]. The long-term allograft failure risk was not significantly different between HIV-negative and HIV-positive patients, considering the competing risk of post-transplant death [sdHR: 1.71 (CI 95%: 0.46 to 6.35)].

Conclusions — Although the incidence and crude probability of kidney transplantation were similar among HIV-negative and HIV-positive patients in this cohort, HIV-infected individuals had a significantly lower likelihood of kidney transplantation than HIV-negative individuals. HIV infection was not significantly associated with a poor long-term allograft outcome compared to HIV-negative patients.