New hope for trans­plant pa­tients

World-first HIV-pos­i­tive liv­ing liver trans­plant presents po­ten­tial new pool of liv­ing donors

Mail & Guardian - - Careers - Dr Har­riet Etheredge, Dr June Fabian and Pro­fes­sor Jean Botha

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 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; 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, among oth­ers, 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, as 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 kid­ney or liver trans­plants.

Although kid­ney trans­plant from liv­ing donors is quite com­mon, liver trans­plant from liv­ing donors 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 an­tiretro­vi­rals 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, but 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 a liv­ing HIV-pos­i­tive adult has do­nated a por­tion of their 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 meant 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 been un­able to find any ev­i­dence of HIV in­fec­tion in the 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 the case is.

Although this is only one case, we have shown the world 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, and 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 HIV­pos­i­tive 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.

For the first time in his­tory, an HIV-pos­i­tive liv­ing adult has do­nated a por­tion of their liver to their HIV-neg­a­tive child. This was done to save the child’s life, says Dr Har­riet Etheredge (left). Pho­tos: Wits Univer­sity

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