The difficulty in timing for liver transplantation in cirrhotic patients coinfected with HIV: in search for a prognosis score

Pros and cons of liver transplantation in human immunodeficiency virus infected recipients

Before the introduction of combined highly active antiretroviral therapy, a positive human immunodeficiency virus (HIV) serological status represented an absolute contraindication for solid organ transplant (SOT). The advent of highly effective combined antiretroviral therapy in 1996 largely contributed to the increased demand for SOT in HIV-positive individuals due to increased patients’ life expectancy associated with the increasing prevalence of end-stage liver disease (ESLD). Nowadays, liver failure represents a frequent cause of mortality in the HIV-infected population mainly due to coinfection with hepatitis viruses sharing the same way of transmission. Thus, liver transplantation (LT) represents a reasonable approach in HIV patients with stable infection and ESLD. Available data presently supports with good evidence the practice of LT in the HIV-positive population. Thus, the issue is no longer “whether it is correct to transplant HIV-infected patients”, but “who are the patients who can be safely transplanted” and “when is the best time to perform LT”. Indeed, the benefits of LT in HIV-infected patients, especially in terms of mid- and long-term patient and graft survivals, are strictly related to the patients’ selection and to the correct timing for transplantation, especially when hepatitis C virus coinfection is present. Aim of this article is to review the pros and cons of LT in the cohort of HIV infected recipients.

Perioperative considerations in HIV-infected liver transplanted patients

The introduction of highly active antiretroviral therapy (HAART) has improved survival in HIV patients, allowing them to undergo liver transplantation (OLT) in cases of end-stage liver disease. HIV patients show a higher incidence of pulmonary hypertension. The aim of this study was to evaluate pulmonary and systemic hemodynamic changes in HIV-infected patients compared with a non-HIV-infected group of patients undergoing OLT.

METHODS

We analyzed 20 HIV-infected patients and 20 non-HIV-infected patients who underwent OLT. We analyzed preoperative cardiovascular status, as well as intra- and postoperative hemodynamic data. Hemodynamic data were recorded at 4 predefined phases during OLT and at 24, 48, and 72 hours after intensive care unit (ICU) admission. We also evaluated the following perioperative aspects: transfusion requirements, postoperative mechanical ventilation time, ventilation time, and length of ICU and of hospital stay.

RESULTS

HIV-positive patients were younger than controls with a greater incidence of coinfection with hepatotropic viruses. One HIV-infected patient died in the ICU. Hemodynamic data showed a higher cardiac index and higher pulmonary vascular resistance index among HIV-infected patients, but without any clinical impact. No significant difference in blood unit transfusions, postoperative time on mechanical ventilation, or length of ICU or hospital stay was observed between the groups.

CONCLUSIONS

Although the number of patients studied is limited, we concluded that HIV-infected patients undergoing OLT showed similar perioperative courses as non-HIV-infected patients.

Impact of human immunodeficiency virus on survival after liver transplantation: analysis of United Network for Organ Sharing database

BACKGROUND

The outcome of liver transplantation (LT) in patients infected with human immunodeficiency virus (HIV) has been a matter of controversy.

METHODS

A retrospective cohort study was performed to assess the impact of HIV on LT survival by using United Network for Organ Sharing registry Standard Transplant Analysis and Research files.

RESULTS

A total of 138 HIV(+) and 30,520 HIV(-) patients who were > or =18 years old and underwent LT during the highly active antiretroviral therapy era (starting January 1, 1997) in the United States were included. Among all HIV(+) patients, the estimated 2-year survival probability was lower (70%) than among non-HIV patients (81%). This excess risk appeared entirely among those with coinfections, that is, HIV with hepatitis B virus or hepatitis C virus (HCV), as none of the 24 HIV-infected patients who did not have hepatitis B virus or HCV died during an average of 1.2 years of follow-up per person. Among HCV(+) patients, those with HIV coinfection had significantly lower survival rates than patients without HIV (P=0.006). Controlling for age, coinfection, Model for End-Stage Liver Disease scores, and other potential confounders in a proportional hazards regression analysis, HIV(+) patients had a hazard ratio of 1.41 (P=0.14, 95% confidence interval: 0.90-2.22) for mortality after LT.

CONCLUSION

HIV(+) patients without HCV coinfection seemed to have good prognosis, whereas patients who had HIV/HCV coinfection had poor outcomes, which were significantly worse than that seen in those with HCV alone.

Survival and recurrence of hepatitis C after liver transplantation in patients coinfected with human immunodeficiency virus and hepatitis C virus

Liver transplantation in patients coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) is a recent indication. In a single center, we have compared the survival and severity of recurrent HCV infection after liver transplantation in HIV-HCV-coinfected and HCV-monoinfected patients. Seventy-nine patients receiving a first liver graft for HCV-related liver disease between 1999 and 2005 were included. Among them, 35 had highly active antiretroviral therapy-controlled HIV infection. All patients were monitored for HCV viral load and liver histology during the posttransplantation course. Coinfected patients were younger (43 +/- 6 versus 55 +/- 8 years, P < 0.0001) and had a higher Model for End-Stage Liver Disease (MELD) score (18.8 +/- 7.4 versus 14.8 +/- 4.7; P = 0.008). The 2-year and 5-year survival rates were 73% and 51% and 91% and 81% in coinfected patients and monoinfected patients, respectively (log-rank P = 0.004). Under multivariate Cox analysis, survival was related only to the MELD score (P = 0.03; risk ratio, 1.08; 95% confidence interval, 1.01, 1.15). Using the Kaplan-Meier method, the progression to fibrosis >or= F2 was significantly higher in the coinfected group (P < 0.0001).

CONCLUSION

The results of liver transplantation in HIV-HCV-coinfected patients were satisfactory in terms of survival benefit. Earlier referral of these patients to a liver transplant unit, the use of new drugs effective against HCV, and an avoidance of drug toxicity are mandatory if we are to improve the results of this challenging indication for liver transplantation.

[Liver transplantation for patients infected with both HIV and HCV or HIV and HBV]

Human immunodeficiency virus infection (HIV) has been considered until recently as a contraindication for liver transplantation. This was due to the poor spontaneous prognosis of HIV infection. The advent of highly active antiretroviral drugs (HAART) was a therapeutic breakthrough, and the prognosis has been dramatically improved. 30 % and 10 % of HIV infected patients are coinfected with hepatitis C virus (HCV) and with hepatitis B virus (HBV), respectively. The progression of chronic hepatitis B and C seems more rapid in coinfected patients, and a high number of patients will develop life-threatening liver cirrhosis. There are numerous potential problems raised by liver transplantation in HIV infected patients: (1) the potential risk of needlestick injury during this type of hemorrhagic surgery at high risk of bleeding; (2) the timing for liver transplantation; (3) the risk of interference between HAART and calcineurin inhibitors; (4) The risk of HBV and HCV recurrence post-transplant. Since 1999, a program of liver transplantation has been started in patients coinfected with HIV and HBV or HCV with the support of the Agence Nationale de Recherche contre le Sida et les Hépatites virales (ANRS). The first results showed that liver transplantation in HIV-HCV and HIV-HBV infected patients is feasible, achieving 2-year survival of 70 % and 100 %, respectively. There was no acceleration of HIV disease after transplantation. HBV recurrence was well prevented by the combination of anti-HBs immunoglobulins plus nucleoside and nucleotide analogues effective against HBV. The main problem is HCV recurrence, which is more rapid and more severe in HIV coinfected patients than in HCV monoinfected patients. Understanding HCV recurrence mechanisms, and preventing and treating of HCV recurrence are major future challenges.

Hepatocellular carcinoma in HIV patients treated by liver transplantation

INTRODUCTION

Several reports have shown the effectiveness of liver transplantation (LT) as a therapeutic option in HIV-patients affected by end-stage liver disease. HCC on cirrhosis is another major indication for LT. However, no reports, to our knowledge, have been published as yet addressing the important questions of indications and outcome of LT in HIV-patients with HCC, mainly because of concerns regarding a more aggressive course of HCC with respect to HCC seen in HIV-negative individuals.

METHODS

The aim of this report is to focus on indications, preliminary results and complications of LT in a group of 7 HIV-patients who underwent LT at our department for HCC on cirrhosis.

RESULTS

Indications to listing HIV-patients were HCC using the internationally accepted Milan criteria. All patients were HBV-and/or HCV-infected. The mean CD4+ cell-count was 249 (range 144-353), and the HIV-RNA load was undetectable in all but one case. After a mean follow-up period of 232days (range 33-774), no recurrence of HCC was seen; one patient died.

CONCLUSION

Characteristics of the study protocol, the patients, virological and immunological features, tumor stage and pre-transplantation treatment, complications and survival are herein described in an effort to provide new insights into methodology for an aggressive management of HCC in HIV patients, and possibly give a greater chance of cure.