Background: Kidney transplantation has been established as the therapy of choice for the treatment of end stage renal disease among appropriately selected HIV-infected (HIV+) individuals. However, acute rejection (AR) rates are more than 2-fold higher than for non-HIV-infected (HIV-) kidney transplant recipients. The optimal immunosuppression strategy for this population remains unknown.

Methods: Associations between immunosuppression regimen and development of AR at 1-year were studied among adult, HIV+, kidney-only recipients using SRTR data from 2003-2011 [n=516]. Relative risk of AR was modeled using modified multivariate Poisson regression adjusting for center participation in the NIH-study protocol, center experience, donor type and age, recipient age and race, PRA, HLA mismatch, cold ischemia time (CIT), and retransplantation. Matched control analysis among anti-thymocyte globulin induced HIV+ and HIV- kidney transplant recipients was performed.

Results: There is no difference in the risk for AR among HIV+ and HIV- anti-thymocyte globulin (ATG) induced recipients [adjusted Relative Risk (aRR) 1.16; 95%CI 0.41-3.35; p=0.77]. Further, HIV+ patients that receive ATG induction have a 2.6 fold lower risk of AR [aRR 0.39; 95%CI 0.18-0.87; p=0.02] compared to no induction therapy. Compared to calcineurin-based (CNI) maintenance therapy, HIV+ recipients maintained on sirolimus-based therapy had a 2.2 fold higher risk of AR [aRR 2.15; 95%CI 1.20-3.86; p=0.01].

Conclusion: These data support a role for ATG-induction therapy in HIV+ individuals undergoing kidney transplantation, and caution against the use sirolimus-based maintenance therapy in this population.

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