KUALA LUMPUR, April 11 – University Malaya Medical Centre (UMMC) has successfully performed the country’s first kidney transplant on a person living with HIV – a groundbreaking procedure in a long marginalised population.
The patient, a man in his 50s who had been living with HIV for over two decades, was suffering from end-stage renal disease – or kidney failure – and had been undergoing peritoneal dialysis to manage his condition. The dialysis proved to be a challenge, and the patient was persistent in exploring his options beyond dialysis, including renal transplantation.
The three-hour surgery at the university hospital took place last year. The patient received a kidney from his wife, who is a HIV-negative donor. Both the patient and donor wished to remain anonymous. The donor was discharged three days after the surgery, while the recipient was discharged after two weeks.
Kidney transplant patients are usually discharged from the hospital after a week if there are no complications. In the case of UMMC’s first renal transplant on a patient living with HIV, the medical team opted to extend the discharge timeline to allow for more thorough observation, despite no occurrence of post-operative complications.
Medical experts in urology, nephrology, and infectious diseases at the Klang Valley university hospital hailed the procedure as a “game changer” for Malaysia that has long struggled with stigma and discrimination against people with HIV. This life-saving option now provides hope for HIV-positive patients with kidney failure.
UMMC’s medical team declined to provide the specific date for the historic kidney transplant because the patient’s family does not know about his HIV status; only that he underwent the surgery.
Assoc Prof Dr Raja Iskandar Shah Raja Azwa, infectious disease consultant at UMMC and president of the Malaysian AIDS Council, described the successful kidney transplant as a “huge win” for people living with HIV in the country.
“The fear of HIV can be so deeply ingrained, often irrationally so, in so many people including our colleagues within health care settings who, are not fully aware of the advances in HIV treatment, and that the life expectancy of people living with HIV now – provided they are on treatment and receiving care – approximates that of a HIV-negative person.
“If people with HIV on treatment are living normal lifespans, there is no reason why they can’t be offered the same standard of care offered to people who do not have HIV,” Dr Raja Iskandar told CodeBlue in an exclusive interview last March 20.
In describing the success of the transplant, Dr Raja Iskandar highlighted the need to always push for progress. “For me, this is also a learning experience to never stop advocating for equitable access to health care for a very marginalised group of people. If it’s a standard of care elsewhere, why shouldn’t it be the standard of care here?”
Standard Surgical Procedures Followed For HIV-Positive Renal Transplantation
One of the surgeons who performed the operation, Assoc Prof Dr Shanggar Kuppusamy, said the transplanted kidney functioned well and there were no signs of rejection. The operation required a team of surgeons performing the donor and recipient surgery, the anaesthetists and nursing teams to all work together to ensure a positive outcome.
“We achieved immediate graft function during the procedure, which indicated that the surgery went very well,” said Dr Shanggar, who currently serves as Head of the Surgery Department and Lead of Transplant Services at UMMC.
“Overall, the surgery followed the standard protocol for renal transplant, and there was not much deviation from our usual approach.”
Dr Shanggar said the surgical team employed universal precautions during the procedure to minimise the risk of infection. This included being fully geared and scrubbed to prevent any potential infections, wearing protective gowns, shields, and gloves, and practising extreme care during tissue and instruments handling. These precautions are standard practice for all patients.
“We do not discriminate against patients based on their background or infectious status. We treat everyone with the same level of care and attention, regardless of their circumstances. We performed a surgery on a patient with Hepatitis C just last week,” said Dr Shanggar.
Needle sticks or sharp injuries are occasional hazards that surgical team members face during operations. However, Dr Raja Iskandar reassured that if a team member were to experience a needle stick injury during the surgery, there would be no cause for concern.
“The patient was receiving treatment and had an undetectable viral load, which essentially means that the level of virus in his blood was so low that it could not be detected by the lab assay.
“The risk of transmission of HIV through a needle stick injury from a person with HIV not on treatment is approximately 0.3 per cent. However, if the patient is on antiretroviral therapy and is undetectable, the risk is likely zero,” explained Dr Raja Iskandar, underscoring the minimal risk of HIV transmission in such scenarios.
How UMMC Evaluates HIV-Positive Patients For Kidney Transplants
UMMC consultant nephrologist Assoc Prof Dr Ng Kok Peng, who first met the patient in 2021, praised the surgeon’s affirmative action despite the patient being the first with HIV to undergo a kidney transplant in the country.
“After we conducted a thorough workup of the patient and presented our findings to the surgical team, they were more than happy to proceed with the operation,” Dr Ng said.
Before the procedure at UMMC, the patient had been unsuccessful in his attempts to convince medical specialists to offer renal transplantation at other hospitals, both locally and abroad, solely due to his HIV status.
Eventually, the patient sought out the expertise of Dr Ng, who consulted with the infectious disease team at UMMC.
“This was the first case we had undertaken at that time, so I definitely needed help from the infectious diseases team on how best to handle such cases.
“This was crucial because we wanted to ensure a successful outcome and demonstrate to the nation that kidney transplantation can be offered as a viable treatment option for those with end-stage kidney disease,” Dr Ng said.
In early 2022, the patient and donor underwent a rigorous six-month series of tests to ensure they were fully prepared for the upcoming surgery. This extended workup period was longer than the typical three-month process for regular transplants.
Dr Lee Yee Wan, a nephrologist at UMMC, and Dr Ng Rong Xiang, an infectious disease physician at the same hospital, jointly oversaw the transplant workup.
“For this case, Dr Rong Xiang and I reviewed all the British and American guidelines and determined that, due to the patient’s HIV status, we needed to conduct additional tests and administer extra vaccinations. The process from our first meeting with the patient to the operation took around five to six months,” Dr Lee explained.
Dr Lee noted that the patient remained motivated and positive throughout the testing period leading up to the transplant. Meanwhile, tests for the donor were routine, as the donor was HIV-negative.
“The workup for the patient was not too different from that for the general population. The only additional thing we did was to recheck the patient’s viral load to ensure it was undetectable and ensure that his current HIV treatment did not pose a risk in terms of drug interactions with his future immunosuppressants,” Dr Rong Xiang said.
Policy Reforms Needed For HIV Patients Seeking Organ Transplants
According to Stanford Medicine, while the United Network for Organ Sharing (UNOS) does not consider HIV infection a contraindication for organ transplantation, individual transplant centres have the discretion to decide whether or not to perform surgery on HIV-positive patients. Kidney transplantation is the standard of care in countries like the United States and the United Kingdom for end-stage renal disease.
In cases of end-stage kidney disease, renal replacement therapies such as haemodialysis and peritoneal dialysis have traditionally been used as alternatives to renal transplantation. This partly explains why renal transplantation was not initially considered a viable option for HIV-infected patients with kidney failure.
However, the success of the groundbreaking surgery at UMMC opens up the possibility of renal transplantation being a feasible treatment for selected HIV-infected patients with end-stage renal disease, either pre-emptively or while on dialysis.
In Malaysia, the first option of renal replacement therapy for people living with HIV and having end-stage kidney disease is peritoneal dialysis, failing which, they will be offered haemodialysis treatment at government hospitals, said Prof Dr Lim Soo Kun, consultant nephrologist and Head of Renal Division at UMMC.
“As of now, there is no private hemodialysis centre which accepts people living with HIV in Malaysia.”
Kidney transplantation in people living with HIV has been performed since the early 2000s in the United States. One US registry report published in 2017 showed that patients with HIV who had undergone kidney transplantation would enjoy the survival benefits 194 days after the operation.
Five-year survival was 90.6 per cent for those transplanted – much more superior than those who remained on dialysis at 80 per cent.
Despite the absence of guidelines that prohibit organ transplantation in HIV-positive patients in Malaysia, the longstanding stigma surrounding HIV often results in it being disregarded as a treatment option and requests being denied, Dr Lim said.
“If we can show that HIV-positive patients can achieve the same outcomes as other patients, there shouldn’t be a different policy in terms of organ transplantation for them. This is the message we want to convey.”
Dr Lim cited the success of previous medical procedures, such as the initial resistance to performing different blood group transplants, as evidence that mindsets can be changed over time.
He believes that the same pattern will emerge with HIV-positive kidney transplants, where other medical professionals will be persuaded to adopt the procedure after reviewing the data.
According to Dr Lim, living donor transplants, which are genetically related or spousal, are the most straightforward method for organ transplantation. However, if this approach gains more acceptance within the nephrology community, the possibility of expanding to deceased donors could arise, which would broaden the donor pool.
“The current number of dialysis patients is exceptionally high, i.e. approximately 50,000, with over 50 per cent of them on the waiting list, and less than 100 deceased donors available each year,” Dr Lim said. “It will take some time to change policies but we have to start somewhere.”
HIV Patients As Drivers Of Change
Dr Raja Iskandar believes that patients have the power to influence the medical community’s approach to organ transplantation for HIV-positive patients. According to him, physicians are more likely to reconsider their stance when faced with persistent requests from patients.
To bring about a change in attitude, Dr Raja Iskandar recommends raising public awareness and educating patients about their options. By doing so, patients will be better equipped to ask their doctors about the possibility of organ transplantation and this could encourage physicians to view this treatment option as a viable solution.
“HIV advocacy has always been generally very strong. Patients have always had to demand and fight for their rights globally, including equal access to health care. But it also takes an exceptional patient to go that extra mile for fear of having a stigmatising disease and in reality, not everybody he encounters is going to be as understanding or accepting.
“It can be very tiring for them in the face of persistent discrimination and rejection. This patient had seen multiple health care professionals, and you can understand that at some point, they will reach a point where they feel they have to give up,” Dr Raja Iskandar said.
“It’s fantastic that this patient persevered, did not give up, and found the right team.”
