Kidney Transplant for HIV-Infected Patients in Renal Failure

PATIENTS: Patients must have documented HIV infection (by any licensed ELISA and confirmation by Western Blot), with confirmation of infection by the clinical pathology lab at the Warren G. Magnuson Clinical Center will be eligible. Patients with renal failure as defined by a creatinine clearance on 24 hour urine collection of less than 20. Patients must be of the ages of 18-60. Patients must have the willingness and legal ability to give informed consent, or permission from a legal guardian. Patients must have the willingness to travel to the Clinical Center for protocol specific samples to be taken, or in some cases, the ability to send samples via overnight mail. Patients must have a current CD4+ T-cell count of greater than or equal to 300/mm(3) for 9 months or longer. Patients must have a CD4 nadir over course of infection not less than 200/mm(3). Patients must have current HIV-1 RNA of less than or equal to 50 RNA copies/ml for 9 months or longer. (Intermittent elevations of less than or equal to 500 copies/ml, if not persistent on more than two sequential measures and followed by undetectable levels, are permitted). Patients must be on a stable HAART -regimen for greater than or equal to 3 months prior to entry. The HAART regimen must consist of at least 3 drugs and include at least 2 classes of drugs. Individuals with sustained viral suppression on a regimen of abacavir plus 2 other nucleoside reverse transcriptase inhibitors will be eligible at the discretion of the investigators. The use of hydroxyurea will not be permitted. Patients must have a willingness to comply with all study medications. Patients must have a willingness to disclose HIV status to their living donor prior to transplant if a living donor is the source of their kidney. Patients must provide adequate medical history documentation to allow for the accurate determination of the severity of one's prior HIV disease status. Patients must not have a history of any AIDS defining opportunistic infections within 5 years of enrollment. Patients must not have a history of any malignant neoplasm except in situ anogenital carcinoma, adequately treated basal or squamous cell carcinoma of the skin, or solid tumors treated with curative therapy and disease free for at least 5 years. Patients must not have infection with a quasi-species of HIV that, based on review of clinical data, antiretroviral treatment history, and available viral genotypes/phenotypes, leaves limited options for successful suppression of viral replication should the patient's current regimen fail. Patients must have the ability and willingness to comply with immunosuppression protocol, antiretroviral therapy, and/or HIV monitoring and therapy if indicated. Patients must not have concomitant conditions that, in the judgement of the investigators, would preclude transplantation or immunosuppression. Patients must not have a condition that precludes serial follow-up. Patients must not have significant coagulopathy or requirement for anticoagulation therapy that would contraindicate protocol allograft biopsies. Donors who are EBV positive when the recipient is EBV negative will be excluded. Donors who are CMV positive when the recipient is CMV negative will be excluded. Patients must not have a history of or active infection with hepatitis B or hepatitis C virus for the first 5 patients. After 5 patients without concomitant hepatitis have been enrolled and followed for 6 months, patients with hepatitis infection without significant fibrosis on liver biopsy will be considered for enrollment. Subjects with a positive donor T cell crossmatch (current or historical) will be excluded. No peak panel reactive antibody greater than 20 percent that is the result of anti-HLA antibodies. DONORS: In addition the above-mentioned criteria, the donor must be HIV, HCV, and HBV negative. EBV and CMV mismatched donors (positive to negative combinations) will also be excluded.