Saturday, April 13, 2019
HIV Patients Should Have Equal Access to Kidney Transplantation Essay Example for Free
human immunodeficiency virus patient ofs Should Have Equal Access to Kidney Transplantation Essayhuman immunodeficiency virus transmitting may be obtained by perseverings receiving nephritic replacement th agepy (RRT) through blood transfusions, renal allo imbed, sexual contacts, or needle sharing of medicine addicts. Viral infection or human immunodeficiency virus-associated nephropathy send away ca commit renal failure. In the early 1980s, prospect of patients with the acquired immunodeficiency syndrome (AIDS) was very low, and option of the fittest rate of human immunodeficiency virus- give individuals with ESRD was miserable.Accordingly, several people even doubted the worth of providing continuance dialysis to patients with AIDS. Due to pull ahead in diagnostic techniques in serologic and viral markers of disease, and use of extremely efficient antiretroviral agents, the prognosis of human immunodeficiency virus-positive individuals has radically improved. Today, skills and knowledge in hemodialysis be effective modes of therapy and many centers, though some argon reluctant, are now starting to set renal transplantation in HIV- infect patients.Human Immunodeficiency Virus HIV infects CD4+ T cells, making the immune system weak as these cells malfunctions. Ab common activation ofCD8= T cells may bear to the loss of both CD4+ AND CD8+ T cells through apoptosis, which may represent a major cause of infected and non-infected cell death in HIV infection. Many HIV-infected individuals proliferative responses to recall antigens, irradiated stimulator peripheral blood mononuclear cells from healthy, orthogonal donors, or T cell mitogens (Roland Stock, 2003).HIV infection nonify worsenedn existing renal disease and can trigger pathologically distinct disease named HIV-associated nephropathy (HIVAN), a focal segmental glomerulosclerosis (FSGS) associated with crude(a) cystic tubular lesions, leading to chronic renal failure. Renal syndromes include fluid and electrolyte malfunction, proteinuria, nephrotic disease, progressive azotemia, reddened kidneys, and fast succession to end full point renal disease (ESRD).HIV-infected patients who developed renal disease withdraw short option span. Transplantation process may increase the stake of HIV-infected patients in accelerating the depletion and dysfunction of their CD4+ T cells, which may pull ahead outgrowth in the development of more serious and complicated disease, such as AIDS, making HIV replication harder to control. On the other hand, immunosuppression might reverse the immuno-pathology associated with HIV disease (Roland Stock, 2003). difference Stage Renal DiseaseWhen the kidney totally lost its ability to filter waste from the circulatory system, renal failure finally meet the end stage renal disease or ESRD, the final stage of nephropathy or the premeditated degeneration of the kidneys. In 1998, everyplace eighty-six thousand patients received therapy for treating ESRD in the joined States. Autonomously, Medicare expenditures rose to 12. 9 billion dollars from 12 billion in 1998. The total cost of ESRD programme through medicare was 17. 9 billion and is now projected to be 28. 3 billion dollars by 2010 (Winsett et al, 2002).The close to common causes of ESRD include diabetic nephropathy, systemic arteral hypertension, glomerul unmatchablephrities, and polycystic kidney disease. In the case of ESRD, GFR declines to less than 10mL/min/m2, once it declines to that level, the practice hemeostatic function of the kidneys can not be sustained anymore. Whatever the cause, if untreated, ESRD may cause severe infection and even death to the patient. When the kidney function decline to less than twelve percent to fifteen percent, the patient survival go out depend on the kidney transplantation and the therapies associated to it (Winsett et al, 2002).Chronic Dialysis versus Kidney Transplantation According to the New England Journal of medicinal drug (1999), transplantation is superior in saving life than long-term dialysis. The mortality rate rank were analyzed among over 200, 000 patients who underwent dialyses for ESRD and precisely twenty-three thousand received a kidney. Based on the research, patients who undergo transplantation become twice more than the projected years of life of patients who remained on the waitlist having dialysis.A successful transplantation improves the tincture of life and lessens the mortality rate for many patients. Moreover, it consumes less time and energy. However, this procedure may cause bleeding, damage, and infection to other variety meat in side the body, even death can occur. That is why after transplantation, patients must undergo immunosuppression process for a lifetime period to monitor signs of rejection (Berns, 2007). Despite the greater risks, when it comes to quality and duration of life, a transplanted kidney is more preferred.Its man over machine. Statistic s Over ten thousand kidney transplantations are being performed each(prenominal) year on patients with ESRD. Records show that patients who undergo kidney transplantation live longer than those who are just winning dialysis but eight to nine patients on the waitlist die every day imputable to scarcity of organs to be used in the transplantation. Cadaveric kidney supply has an average of more than devil years to come, and only 15-20 % of patients in the list were granted to receive them.The condition of renal failure and what causes them consume direct effects on the transplantation rates of patients. Individuals with cystic kidney disease (25. 5%), obstructive nephropathy (24. 9%), and glomerulonephrities (23. 2%) select the utmost successful transplantation rate while patients having diabetes (13. 3%) and hypertension (8. 5%) cod the lowest rates (Wallace, 1998). Why transplantation should be considered in HIV-infected patients? Organ malfunction has been the principal rea son of morbidity and mortality of HIV-infected patients, AIDS-related complication is only secondary.Before, immunosuppression was thought to be an unconditional contraindication in the circumstance of HIV infection, now, it is gradually more valued that immune activation is a major aspect of HIV pathogenesis. Consequently, immunosuppression has good effects in people with HIV infection through temperance of immune activation or reducing of HIV reservoirs. Some specific immunosuppressive drug agents also begin antiviral properties or interact synergistically with certain antiretroviral agents (Roland Stock, 2003).Reasons for reluctance of performing Kidney Transplantation for HIV-infected patients In a survey conducted to 248 renal transplant centers in The U. S. in 1998, 148 requires HIV testing of prospective kidney telephone receivers and that the vast majority denies patients with HIV to undergo transplantation. Most centers weigh that transplantation is not suitable for HIV -infected patients (Spital A. , 1998). Before, chronic dialysis was the only option for treating ESRD of HIV-infected patients for fear of increased morbidity and mortality due to therapeutic immunosuppression.The allocation of cadaver kidneys to these patients was also considered improper due to pass judgment inferior patient graft survival (Anil Kumar et al. , 2005). Also, according to the research led by Professor Andrew Grulich from the University of the New South Wales matter Centre in HIV Epidemiology and Clinical Search (NCHECR), immune deficiency is responsible for the increased risk of contracting several types of cancer than the general population.HIV patients are eleven times more expected to develop Hodgkins lymphoma while in that respect is almost four times the risk for those who had transplants (Staff Writers, 2007). Professor Grulich further proposed that peoples immune system must be maintained at a high level through the use of anti-retroviral drugs. The main h istorical exclusion of HIV-infected patients with ESRD was rooted in the coherent fundament that immunosuppression necessary for organ transplantation would aggravate an already immunocompromised state.Although there were numerous initial reports signifying worse outcomes after solid organ transplantation in HIV seropositive recipients, there have been reports as swell suggesting there were no unpleasant effects of HIV infection on allograft survival (University of California, 2007). Indeed, there have been two reports of HIV-infected patients going through liver or renal transplantation who demonstrate normal graft function for at least eight years following the transplant.The HIV status of the two was unknown at the time of transplantation therefore no endeavors were prepared to adjust immunosuppressive therapy. The musical note in these studies may recount to differences in the time of HIV acquisition, with those of longstanding HIV infection prior to transplantation having a faster end relative to those who acquired HIV infection at the time of transplantation. disregarding of standard cyclosporine-based immunosuppressive treatments, there was no proof of OI or progression to AIDS in the beginning eight years following transplantation (Roland Stock, 2003).There are multiple other reports of patients with HIV who had deceased through transplantation and demonstrated long-term graft survival in the presence of immunosuppression with variable rates of developing AIDS or death. Six of eleven renal allografts were functioning at a destine follow-up of thirty-one months (Roland Stock, 2003). Effects of Immunosuppressant Agents In order to avoid rejection reaction of the body against transplanted organs, immunosuppressant drugs are being taken to block the immune system from attacking the transplanted organ and preserving its function.As side effect, these drugs can help in HIV progress to AIDS. However, recent studies show that these drugs can also con tribute in the reduction of HIV. Inactive T lymphocytes serve as a vital reservoir for HIV regardless of highly active antiretroviral therapy. Immunosuppression may affect the reservoir of HIV-infected cell that persist throughout highly active antiretroviral therapy through reduction of cell-associated HIV by either direct inhibition of viral replication, potentiation of HAART effects, or exhaustion of infected cells and lessening in the accessibility of permissive target cells by preventing T-cell activation.Otherwise, improvement in viral reservoirs can be caused by minify immune management of HIV-expressing cells (Roland Stock, 2003). Ethical and Medical Issues Organ shortage is one of the ethical issues in organ transplantation. One distributive fairness criteria is equal access which include length of time waiting (first come, first saved basis), and age (youngest to oldest). The supporters of this criteria has a strong belief that since kidney transplantation can save live, it is an important remedial practice and worth offering to anyone who needs it (Center for Bioethics, 2004).The second type is the utmost benefit, aiming to maximize the quantity of successful transplants. The maximum benefit criteria include medical need (the sickest people are being prioritized for a transplantable organ), and probable success of a transplant (giving organs to the person who will be most likely to live the longest). People who support the maximum benefit philosophy train to avoid the wasting of organs, which are quite scarce, so that the greatest benefit is derived from every available organ (Center for Bioethics, 2004).During the Pre-HAART era, HIV-infected patients have a very poor prognosis, many people believes that it would be a waste to use the limited supply of organ to those group of patients that is why many transplant centers are reluctant to practice the transplantation. However, now that the HAART has been launched and the mortality and morbidity ra te has been decreasing, it would be unethical to withhold this option in the absence of evidence that it is either unsafe or ineffective. Advancement in HIV Therapy HAART eraHighly Active Antiretroviral Therapy (HAART) has been the primary improvement in the treatment of HIV-infected patients in the previous decade. Numerous studies and observations had turn up that advantageous outcomes of HAART also include improvement of HIV-related renal complications. Virologic and histologic evidences imply that HIVAN perhaps the result of HIV-1 reproduction in the kidney. The potential relation of HIVAN with HIV-1 replication in the kidney is associated with epidemiologic and medical records showing that HAART may improve HIVAN.On the other hand, from nephrologists perspective, one effect of this achievement has been the emergence of crudefound kidney diseases related to (1) enhanced management of the HIV infection and (2) the prospective nephroxicity of antiretroviral treatments. Accordin g to the studies of MD Roland and Stock, medical tests have confirmed apparent survival benefits linked with the use of protease inhibitor (PI)-containing or non-nucleoside reverse-transcriptate inhibitor (NNRTI)-containing regimens (HAART).Epidemiologic statistics show reduced mortality, hospitalization rates, and opportunistic infection (OI) incidence associated with HAART. There have been vivid decline in new AIDS-related OIs, the majority of which are now occurring in people with low CD4+ T cell counts and those who are not receiving medical care (University of California, 2007). Epidemiologic and modeling information sustain the clinical trial efficacy data, signifying that HAART has a considerable effect on medical result (Roland Stock, 2003). Survival RateUsing the United States Kidney Data carcass (USRDS) data, the Journal of the American Society of Nephrology analyzed and studied these inputs to find out whether recipient HIV serologic status remains the primary factor in graft and patient survival in modern clinical transplantation. Ninety-five percent of the HIV-infected patients survived after transplantation and only 4. 3% died. Although in the earlier USRDS studies of kidney recipients before the introduction of HAART, the results showed that HIV-infected recipients had a survival of eighty-three percent while the uninfected patients have eighty-eight percent survival rates.While endurance records of HIV-infected and HIV-uninfected patients is almost the same, selection bias may have occurred, prioritizing the healthier patients than HIV-infected individuals. Also, in the studies of MD Roland, data showed that graft survival and rejection rates of HIV-infected patients who had gone through transplantation were similar to those HIV-negative patients (Roland Stock, 2003). Studies and Observations Methods.This study aims to observe safety and success of kidney transplantation, and learn the effects of immunosuppressant treatments on HIV infection , with the approval of the Institutional evaluation board of two universities the Drexel University College of Medicine and Hahnemann University Hospital. Forty-five recipients with HIV infection from February 2001 to January 2004 were observed. Patient inclusion criteria were maintenance of HAART, plasma HIV-1 RNA of 400 copies per milliliter, absolute CD4 counts of at least 200 cells per little liter.Immunosuppressant treatment includes the use of basiliximab stimulation and maintenance with cyclosporine, sirolimus, and steroids while HAART was still being use after the transplant. Biopsy detected acute rejection methylprednisolone was used as a treatment. Every after twelve months, superintendence biopsies are being done and evaluations include testing for subclinical acute rejection, chronic allograft nephropathy, and HIVAN (Anil Kumar et al. 2005). Results. The results demonstrated that patients with HIV infection who maintained HAART are capable of increasing an immune react ion, as turn out by twenty-five percent rejection rate, signifying allograft reactivity is preserved and that no immunosuppression will lead to allograft rejection. The data showed that the combination of HAART and low-dose immunosuppressant drugs is not associated with serious adverse effects (Anil Kumar et al, 2005).The records show one- and biyearly patient survival rate of eighty-five percent and eighty-two percent respectively, in comparison to the describe fifty-eight percent and forty-one percent survival of patients on dialysis. The United States Renal Data System accounted a one-year death rate of 32. 7% in HIV patients uphold on dialysis. The graft survival in this series of HIV-infected recipients is comparable to the UNOS data on non-HIV recipients (Anil Kumar et al, 2005).The monitoring of combined immunosuppression and HAART due to major drug interactions needs thorough supervision and synchronized care of transplant professionals, pharmacists, and HIV specialists. The overall result of this study proves that kidney transplantation in selected HIV-positive patients who were maintained on effective HAART is safe and has high one to two year patient survival compared to dialysis treatment of selected HIV patients. Actual graft survival in HIV recipients is equivalent to other high-risk groups.The patients observed didnt developed AIDS or opportunistic infection caused by immunosuppressant agents. Therefore, positive HIV status should not be considered a contraindication for kidney transplantation in selected patients. Conclusion Ethical concerns and safety of transplantation and post-transplant immunosuppressant treatment in HIV-positive recipients advances radically in recent years. Due to improvements in morbidity and mortality, the safety of this complicated intervention was further evaluated.The former outcomes are promising. Proper management and control of transplantation team will determine the success of the renal transplantation. Sin ce many advancements and developments regarding the HIV therapy, kidney transplantation is now possible for HIV-infected patients as morbidity and mortality rate keeps on decreasing. Therefore, with all the results of the research studies and observations, there is sufficient evidence that can support the equal access of patients with HIV infection on kidney transplantation.