Liver transplantation in human immunodeficiency virus-positive patients

Liver Transplantation for HCC in HIV-Infected Patients: Long-Term Single-Center Experience

BACKGROUND

HIV-infected patients now have long life expectation since the introduction of the highly active antiretroviral therapy (HAART). Liver diseases, especially cirrhosis and hepatocellular carcinoma (HCC), currently represent a leading cause of death in this setting of patients.

AIM

To address the results of liver transplantation (LT) for HCC in HIV-infected patients.

METHODS

All patients with and without HIV infection who underwent LT for HCC (n = 420) between 2001 and 2021 in our center were analyzed with the intent of comparing graft and patient survival. Cox regression analysis was used to determine prognostic survival factors and logistic regression to determine the predictor factors of post-LT recurrence.

RESULTS

Among 1010 LT, 32 were HIV-infected recipients. With an average follow-up of 62 ± 51 months, 5-year overall survival in LT recipients with and without HIV-infection was 71.6% and 69.9%, respectively (p = ns), whereas 5-year graft survival in HIV-infected and HIV-non infected was 68.3% and 68.2%, respectively (p = ns). The independent predictive factor of survival in the study group was: HCV infection (HR 1.83, p = 0.024). There were no significant differences in the pathological characteristics of HCC between the two groups. The logistic regression analysis of the study population demonstrated that microvascular invasion (HR 5.18, p< 0.001), HCC diameter (HR 1.16, p = 0.028), and number of HCC nodules (HR 1.26, p = 0.003) were predictors of recurrence post-LT.

CONCLUSION

Our study shows that HIV patients undergoing LT for HCC have comparable results in terms of post-LT survival. Excellent results can be achieved for HIV-infected patients with HCC, as long as a strategy of close surveillance and precise treatment of the tumor is adopted while on the waiting list.

Impact of psychosocial comorbidities on clinical outcomes after liver transplantation: Stratification of a high-risk population

BACKGROUND

Liver transplantation is the accepted standard of care for end-stage liver disease due to a variety of etiologies including decompensated cirrhosis, fulminant hepatic failure, and primary hepatic malignancy. There are currently over 13000 candidates on the liver transplant waiting list emphasizing the importance of rigorous patient selection. There are few studies regarding the impact of additional psychosocial barriers to liver transplant including financial hardship, lack of caregiver support, polysubstance abuse, and issues with medical non-compliance. We hypothesized that patients with certain psychosocial comorbidities experienced worse outcomes after liver transplantation.

AIM

To assess the impact of certain pre-transplant psychosocial comorbidities on outcomes after liver transplantation.

METHODS

A retrospective analysis was performed on all adult patients from 2012-2016. Psychosocial comorbidities including documented medical non-compliance, polysubstance abuse, financial issues, and lack of caregiver support were collected. The primary outcome assessed post-transplantation was survival. Secondary outcomes measured included graft failure, episodes of acute rejection, psychiatric decompensation, number of readmissions, presence of infection, recidivism for alcohol and other substances, and documented caregiver support failure.

RESULTS

For the primary outcome, there were no differences in survival. Patients with a history of psychiatric disease had a higher incidence of psychiatric decompensation after liver transplantation (19% vs 10%, P = 0.013). Treatment of psychiatric disorders resulted in a reduction of the incidence of psychiatric decompensation (21% vs 11%, P = 0.022). Patients with a history of polysubstance abuse in the transplant evaluation had a higher incidence of substance abuse after transplantation (5.8% vs 1.2%, P = 0.05). In this cohort, 15 patients (3.8%) were found to have medical compliance issues in the transplant evaluation. Of these specific patients, 13.3% were found to have substance abuse after transplantation as opposed to 1.3% in patients without documented compliance issues (P = 0.03).

CONCLUSION

Patients with certain psychosocial comorbidities had worse outcomes following liver transplantation. Further prospective and multi-center studies are warranted to properly determine guidelines for liver transplantation regarding this high-risk population.

Successful Treatment of Mitochondrial Toxicity in an HIV-Positive Patient After Liver Transplantation

Liver transplantation in patients infected with the human immunodeficiency virus (HIV) has been increasingly performed with reasonable outcomes; however, medical management of both immunosuppression and antiretroviral therapy can be challenging owing to drug toxicities and interactions. Nucleoside reverse transcriptase inhibitors (NRTIs), a common backbone of highly active antiretroviral therapy (HAART), were the first class of effective antiretroviral drugs developed. NRTIs are commonly used for posttransplant HAART therapy and have a rare but fatal complication of mitochondrial toxicity, manifesting as severe lactic acidosis, hepatic steatosis, and lipoatrophy. Herein, we have reported on the first known successful treatment of severe mitochondrial toxicity secondary to NRTIs in an HIV-infected transplant recipient.

Determinants of HIV outpatient service utilization: a systematic review

Demands on HIV services are increasing as a consequence of the increased life-expectancy of HIV patients in the highly active antiretroviral therapy era. Understanding the factors that influence utilization of ambulatory HIV services is useful for planning service provision. This study reviewed factors associated with utilization of hospital based HIV out-patient services. Studies reporting person-based utilization rates of HIV-specific outpatient services broken down by patient or healthcare characteristics were eligible for inclusion. The Andersen Behavioral Model was used to organize the information extracted into pre-disposing, enabling and need components. Ten studies were included in the final review. Older age, private insurance, urban residence, lower CD4 counts, a diagnosis of AIDS, or anti-retroviral treatment were associated with higher utilization rates. The results of this review are consistent with existing knowledge regarding HIV patients' use of health services. Little information was identified on the influence of health service characteristics on utilization of out-patient services.

Liver transplantation for HIV/hepatitis C virus co-infected patients

Since the introduction of antiretroviral therapy (ART) in the mid-1990s, AIDS-related death has been dramatically reduced, and hepatitis-C-virus (HCV)-related liver failure or hepatocellular carcinoma has currently become the leading cause of death in HIV/HCV co-infected patients. Liver transplantation may be one of the treatments of choices in such cases, but the indications for transplantation, perioperative management including both HIV and HCV treatments, immunosuppression and the prevention/treatment of infectious complications are all still topics of debate. With the improved understanding of the viral behaviors of both HIV and HCV and the development of novel strategies, especially to avoid drug interactions between ART and immunosuppression, liver transplantation has become a realistic treatment for HIV/HCV co-infected patients.

Liver abnormalities in the immunosuppressed

The immunosuppressed state may arise due to medical illness or drug therapy, which can result in a diverse array of liver derangements. This article discusses the commonly-encountered immunosuppressed conditions and the associated specific liver diseases. Due to the frequency of blood-borne viral disease globally, viral hepatitis (hepatitis B and C) during chemotherapy, transplantation and the increasingly utilised biological therapies for autoimmune disorders is discussed. An overview of human immunodeficiency virus co-infection with hepatitis B and C is provided. This article aims to highlight the variety of liver diseases which can occur in clinically relevant, particularly iatrogenic, immunosuppressed conditions, and summarise learning and practice points for clinicians. Recognition and prevention of viral liver disease is crucial and early involvement of experts prior to administration of immunosuppressive therapy is advised.

Management of Hepatitis B Virus Infection in Liver Transplantation Setting; The Rising Concerns and Growing Hopes, Report From 10th Congress of the Iranian Society for Organ Transplantation, 2011, Shiraz, Iran

Hepatitis B infection is the main cause of liver related mortality in many countries including Iran. Liver transplantation in cirrhosis due to HBV infection before 1990 was an absolute contraindication. Recurrent infection was a significant event in post liver transplant setting and resulted in increased risk of graft failure and death except successful transplanted individuals. Advances in antiviral prophylaxis have now made graft reinfection majority patients as a rare event. Graft and patient survival have been improved significantly during the past two decades, and consequences of transplantation for hepatitis B virus are now superior to those achieved for most other indications. This has encouraged many centers including the major liver transplantation center of Iran, in Shiraz, to provide liver transplantation to more patients with HBV related end stage liver disease. Management of these patients begins before transplantation along with special care after transplantation. There are some myths and doubts in the management of these patients and one should always balance the cost and efficiency. One of the major concerns is the high economic and social cost of recurrence and all possible efforts should be performed to avoid the ominous consequences of reinfection. Having a clear scientific grasp on the management of HBV cirrhosis before and after liver transplantation, options and protocols, and changing the concept which HBV infected are contraindicated ones for liver transplantation, and future hopes in increasing patients survival after liver transplantation using the new nucleosides analogues and availability of hepatitis B immunoglobulin in the transplantation setting. This scientific report paper outlines the insights communicated at the HBV and liver transplantation symposium during 10th Congress of the Iranian Society for Organ Transplantation, May 2011, Shiraz, Iran.

Is it safe to use a liver graft from a Chagas disease-seropositive donor in a human immunodeficiency virus-positive recipient? A case report addressing a novel challenge in liver transplantation

This is the first report presenting a human immunodeficiency virus (HIV)-positive patient with fulminant hepatic failure receiving a liver graft from a Chagas disease-seropositive deceased donor. We describe the history of a 38-year-old HIV-positive female patient who developed fulminant hepatic failure of an autoimmune etiology with rapid deterioration of her clinical status and secondary multiorgan failure and, therefore, needed emergency liver transplantation (LT) as a lifesaving procedure. Because of the scarcity of organs and the high mortality rate for emergency status patients on the LT waiting list, we decided to accept a Chagas disease-seropositive deceased donor liver graft for this immunocompromised Chagas disease-seronegative patient. The recipient had a rapid postoperative recovery and was discharged on postoperative day 9 without prophylactic treatment for Chagas disease. Fifteen months after LT, she was still alive and had never experienced seroconversion on periodic screening tests for Chagas detection. Although there is an inherent risk of acute Chagas disease developing in seronegative recipients, our report suggests that these infected organs can be safely used as a lifesaving strategy for HIV patients with a high need for LT.

Risk factors for infection after liver transplantation

Infection is a common cause of morbidity and mortality after liver transplantation. Risk factors relate to transplantation factors, donor and recipient factors. Transplant factors include ischaemia-reperfusion damage, amount of intra-operative blood transfusion, level and type of immunosuppression, rejection, and complications, prolonged intensive care stay with dialysis or ventilation, type of biliary drainage, repeat operations, re-transplantation, antibiotics, antiviral regimen, and environment. Donor risk factors include infection, prolonged intensive care stay, quality of the donor liver (e.g. steatosis), and viral status. For the recipient the most important are MELD score >30, malnutrition, renal failure, acute liver failure, presence of infection or colonisation, and immune status for viruses like cytomegalovirus. In recent years it has become clear that genetic polymorphisms in innate immunity, especially the lectin pathway of complement activation and in Toll-like receptors importantly contribute to the infection risk after liver transplantation. Therefore, the risk for infections after liver transplantation is a multifactorial problem and all factors need attention to reduce this risk.

Subtle hepatocellular carcinoma: a persisting role for alpha-fetoprotein monitoring in high-risk patients with cirrhosis

Hepatocellular carcinoma (HCC) is a common, aggressive malignancy that usually develops in a background of liver cirrhosis. Practice guidelines recommend screening of cirrhotic patients with ultrasound and more detailed imaging (computed tomography or magnetic resonance imaging) if abnormalities are detected. The utility of alpha-fetoprotein levels in HCC surveillance is controversial. Although HCC risk differs by etiology of cirrhosis, screening and surveillance guidelines are uniform after cirrhosis is established. We report a case of rapidly progressive HCC occurring in a cirrhotic patient with multiple unique risk factors for neoplasia, detected by a rising alpha-fetoprotein level without imaging features of liver cancer.