New hope for transplant patients
World-first HIV liver transplant presents potential new pool of living donors that could save more lives. In 2017, our multi-disciplinary team at Wits Donald Gordon Medical Centre in Johannesburg performed what was, to the best of our knowledge, the world’s first living donor liver transplant from an HIV positive mother to her HIV negative child. It took us months of careful and thorough deliberation to arrive at the decision to do this procedure, and along the way we had to consider how we had come to be in the position where this type of transplant was our only remaining option.
To make sense of our decision, we have to go back to the basic principles of organ donation, which are universal. There are two types of organ donors. The first are “deceased donors”. Deceased donors are people whose death is confirmed using very specific neurological criteria and these criteria are endorsed by South African law. Deceased donors can donate all their major organs (heart, lungs, kidneys, liver, pancreas) and tissue (skin, bone, blood).
The second type of organ donor is the living donor. People who are living can donate a kidney (because we all have two kidneys but most of us only need one) and a segment of their liver (because the liver regenerates).
Doctors prefer to use organs from deceased donors. The simple reason for this is that surgery for a living donor carries significant risk for someone who is perfectly healthy.
In South Africa, like in many parts of the world, it’s not always possible to help people with organ failure because we have a serious shortage of deceased donor organs. The sad reality is that many people, including children, die while waiting for a transplant. There are several reasons for the organ shortage in South Africa but the most common is that many of us don’t know much about the benefits of donating organs to help others. Because we don’t have enough deceased donors, we have to consider living donors for some people who require a kidney or liver transplant.
Although kidney transplant from living donors is quite common, liver transplant from living donor is much less so. In fact, Wits Donald Gordon Medical Centre is currently the only hospital in South Africa that offers this procedure– and the procedure is equally available to state and private patients, through collaboration with the National Department of Health.
In this particular and unique case, we had a child who was critically ill with liver failure from a condition that was present at birth, and had nothing to do with the pregnancy or the mother’s HIV status. The mother knew her HIV positive status and she took antiretroviral therapy during her pregnancy to prevent infecting her baby. The baby also received antiretroviral therapy after birth to prevent infection.
The child was on our waiting list for a deceased donor, however, over time the child became severely ill, with several admissions to hospital. We realised that if we did nothing, the child was going to die. At the same time, the child’s mother asked us, repeatedly, to consider her as a living donor.
Accepting organs from deceased donors with HIV has been controversial. Previously, deceased HIV positive donation was banned in the United States, but then a team in Cape Town gave a kidney from a deceased HIV positive donor to an HIV positive recipient, and showed it was a safe and effective procedure.
The transplant we performed takes this a few steps further. As far as we know, this is the first time an HIV positive adult has donated a portion of liver to their HIV negative child. Because this kind of transplant has never been done before, we ensured it was done in a very controlled way. This means we could check that the mother had no HIV circulating in her blood at the time of the operation, and we were able to start the child on antiretroviral therapy before the operation.
It is now more than a year since the operation and both mother and child are alive and thriving. Furthermore, even with very sophisticated testing, we have not been able to find any evidence of HIV infection in blood of the child. We are not sure whether the child is HIV positive or HIV negative but will undertake further research to establish what is happening.
Although this is only one case, we have shown that this kind of transplant is possible. It opens up a new era of transplantation in South Africa where we have a dire shortage of deceased donor organs, a very high prevalence of HIV, but the largest antiretroviral treatment programme in the world. This success in HIV management has created a pool of young people living with HIV who have children who contract life-threatening illnesses – as even children of HIV negative parents do.
Sometimes, the children of HIV positive parents also get end-stage liver failure unrelated to HIV, and their children need transplants. The question to us was: “Why not consider these parents as donors?” After all, HIV is a chronic but now entirely manageable disease.
Dr Harriet Etheredge is a medical bioethicist and oversees ethics and regulatory affairs at the Wits Donald Gordon Medical, Dr June Fabian is research director at the Wits Donald Gordon Medical Centre and Transplant surgeon Jean Botha is the Director of the Transplant Unit at Wits Donald Gordon Medical Centre and Professor of Surgery in the Wits Department of Surgery