Abstract Introduction Modern antiretroviral therapy and multidisciplinary care have made lung transplantation feasible for people with HIV, yet data on perioperative complications and mid-term outcomes remain limited. We report aggregated outcomes from four consecutive bilateral lung transplants performed in HIV+ patients at our center. Case Description We transplanted four HIV+ patients on antiretroviral treatment between June 2017 and October 2025. All four recipients underwent bilateral transplantation with basiliximab induction. Median age at transplant was 64 years (range, 37-68 years). Indications included COPD (n = 2) and fibrotic diseases (n = 2). Pre-transplant HIV RNA was undetectable in all four patients at transplant. Maintenance immunosuppression was tacrolimus, mycophenolate, and prednisone with protocolized opportunistic prophylaxis. Extracorporeal membrane oxygenation (ECMO) was used in three cases: veno-arterial intraoperatively in two patients and brief veno-venous rescue early post-operatively in one; all were weaned successfully. Donor respiratory cultures included Klebsiella and E. coli in two cases and were treated per protocol. Primary graft dysfunction at 72 hours (PGD72) ranged from grade 0 to 2. Alloimmunity highlights included: (1) one weak retrospective T/B-cell crossmatch attributed to HIV-related hypergammaglobulinemia; (2) isolated T-cell positivity considered a non-HLA artifact; (3) de novo DP14 donor-specific antibody treated with intravenous immunoglobulin (IVIG), and (4) one patient with recurrent acute cellular rejection and antibody-mediated rejection requiring antithymocyte globulin (ATG) with progression to CLAD-BOS. Infectious events (e.g., airway Candida; later Pseudomonas pneumonia and giardiasis) were managed without lasting graft sequelae in survivors. At last follow-up, three patients were alive; one patient died approximately five years after transplant from non-primary pulmonary causes. Discussion Lung transplantation can be safely performed in HIV+ patients with undetectable viral load. Early graft outcomes were acceptable, and ECMO was feasible as planned intraoperative support or bridge to recovery. Careful interpretation of crossmatch/DSA signals (including potential non-HLA artifacts) and timely escalation of immunosuppression may mitigate downstream alloimmune risk. Lung transplantation in carefully selected HIV+ lung transplant candidates had acceptable peri-operative and mid-term outcomes. This abstract is funded by: None
Muldiiarov et al. (Fri,) studied this question.