Temporal Trends and Outcomes in Liver Transplantation for Recipients With HIV Infection in Europe and United States

Current status of liver transplantation for human immunodeficiency virus-infected patients in mainland China

According to the report from the Chinese Center for Disease Control and Prevention, the prevalence of human immunodeficiency virus (HIV) infection exceeded 1.2 million individuals by the year 2022, with an annual increase of about 80000 cases. The overall prevalence of hepatitis B surface antigen among individuals co-infected with HIV reached 13.7%, almost twice the rate of the general population in China. In addition to the well-documented susceptibility to opportunistic infections and new malignancies, HIV infected patients frequently experience liver-related organ damage, with the liver and kidneys being the most commonly affected. This often leads to the development of end-stage liver and kidney diseases. Therefore, organ transplantation has emerged as an important part of active treatment for HIV infected patients. However, the curative effect is not satisfactory. HIV infection has been considered a contraindication for organ transplantation. Until the emergence of highly active anti-retroviral therapy in 1996, the once intractable replication of retrovirus was effectively inhibited. With prolonged survival, the failure of important organs has become the main cause of death among HIV patients. Therefore, transplant centers worldwide have resumed exploration of organ transplantation for HIV-infected individuals and reached a positive conclusion. This study provides an overview of the current landscape of HIV-positive patients receiving liver transplantation (LT) in mainland China. To date, our transplant center has conducted LT for eight end-stage liver disease patients co-infected with HIV, and all but one, who died two months postoperatively due to sepsis and progressive multi-organ failure, have survived. Comparative analysis with hepatitis B virus-infected patients during the same period revealed no statistically significant differences in acute rejection reactions, cytomegalovirus infection, bacteremia, pulmonary infections, acute kidney injury, new-onset cancers, or vascular and biliary complications.

Clinical outcomes of liver transplantation in human immunodeficiency virus/hepatitis B virus coinfected patients in China

BACKGROUND

Highly active antiretroviral therapy (HAART) has been able to improve the immune system function and survival of human immunodeficiency virus (HIV) patients. However, Patients coinfected with HIV and hepatitis B virus (HBV) are more likely to develop end-stage liver disease (ESLD) than those infected with HBV alone. Consequently, liver transplantation is often required for these patients. This study evaluates the outcomes of orthotopic liver transplantation (OLT) of HIV-HBV coinfected patients in China.

METHODS

We conducted a retrospective analysis on all HIV-HBV coinfected patients that underwent OLT from April 1, 2019 to December 31, 2021 and their outcomes were compared to all HBV monoinfected patients undergoing OLT during the same period. Patient outcomes were determined, including cumulative survival, viral load, CD4 T-cell count and postoperative complications.

RESULTS

The median follow-up of HIV recipients was 36 months after OLT (interquartile range 12-39 months). Almost all patients had stable CD4 T-cell count (> 200 copies/ul), undetectable HBV DNA levels, and undetectable HIV RNA load during follow-up. The 1-, 2-, and 3-year posttransplant survival rates were 85.7% for the HIV group (unchanged from 1 to 3 years) versus 82.2%, 81.2%, and 78.8% for the non-HIV group. Cumulative survival among HIV-HBV coinfected recipients was not significantly different from the HBV monoinfected recipients (log-rank test P = 0.692). The percentage of deaths attributed to infection was comparable between the HIV and non-HIV groups (14.3% vs. 9.32%, P = 0.665). Post OLT, there was no significant difference in acute rejection, cytomegalovirus infection, bacteremia, pulmonary infection, acute kidney injury, de novo tumor and vascular and biliary complications.

CONCLUSIONS

Liver transplantation in patients with HIV-HBV coinfection yields excellent outcomes in terms of intermediate- or long-term survival rate and low incidence of postoperative complications in China. These findings suggest that OLT is safe and feasible for HIV-HBV coinfected patients with ESLD.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2300067631), registered 11 January 2023.

Expanding Access to Organ Transplant for People Living With HIV: Can Policy Catch Up to Outcomes Data?

Advances in antiretroviral and immunosuppressive regimens have improved outcomes following solid organ transplantation in people living with HIV (PLWH). The HIV Organ Policy and Equity Act was conceived to reduce the discard of HIV-positive organs and improve access to transplant for PLWH. Nevertheless, PLWH continue to experience disproportionately low rates of transplant. This overview examines the hurdles to transplantation in PLWH with end-organ disease, the potential and realized impact of the HIV Organ Policy and Equity Act, and changes that could permit expanded access to organ transplant in this population.

Liver transplantation for people of minoritised sexual and gender identities in the USA

The number of people who report to be of minoritised sexual or gender identities in the USA, including lesbian, gay, bisexual, transgender, queer, and other sexuality-diverse and gender-diverse identities, has been increasing in the past decade. This diverse and unique population continues to experience not only health disparities but also psychosocial, economic, and legal disparities in accessing and receiving health care, including liver transplantations. As liver transplantation is life-saving for people with end-stage liver disease, understanding the factors that can affect access to and quality of liver transplantation care in people of minoritised sexual and gender identities in the USA, including differential social supports, insurance coverage, and medical and psychiatric comorbidities, is crucial. Actions, such as collecting sexual orientation and gender identity data, implementing inclusive language, recognising implicit biases, building diverse teams, providing a safer environment, and supporting further research to understand the unique health challenges are needed to ensure equitable access to high-quality liver transplantation care for people of minoritised sexual and gender identities.

Haematopoietic stem-cell transplantation in an HIV endemic area: time to consider donors exposed to or living with HIV

South Africa has more than 8 million people living with HIV. However, the number of patients undergoing haematopoietic stem-cell transplantation (HSCT) in South Africa is far below the target number. Donor numbers are insufficient to meet demand. Both HSCT and solid organ transplantation have proved successful in people living with HIV. Solid organ transplantation also has good outcomes when both donors and recipients have HIV. This Personal View explores the possible inclusion of people living with HIV and umbilical cord blood from HIV-negative infants exposed to HIV as donor sources for HSCT. Beyond the risk of HIV transmission, additional complications must be considered, such as delayed or inadequate immune reconstitution and an increased risk of haematological abnormalities and malignancies. Interactions between antiretroviral drugs and drugs used in the conditioning regimen, as well as the need to maintain virological suppression when gastrointestinal absorption deteriorates, are additional complicating factors. The process also requires more stringent ethical processes to be in place to minimise physical and emotional harm. However, in an HIV endemic country, people living with HIV or donors exposed to HIV must be considered as part of a multidisciplinary collaborative effort to provide more patients with the opportunity to have a life-saving HSCT.

Proceedings of the 27th Annual Congress of the International Liver Transplantation Society

After a virtual congress in 2021 and a previous absence in 2020 because of the coronavirus disease 2019 pandemic, the 27th Annual Congress of the International Liver Transplantation Society was held from May 4 to 7, 2022, in a hybrid format in Istanbul, with 1123 (58% on-site) liver transplant professionals from 61 countries attending the meeting. The hybrid format successfully achieved a balance of much yearned-for "in-person interaction" and global online participation. Almost 500 scientific abstracts were presented. In this report, the Vanguard Committee aims to present a summary of key invited lectures and selected abstracts for the liver transplant community.

Improved Survival After Liver Transplantation for Patients With Human Immunodeficiency Virus (HIV) and HIV/Hepatitis C Virus Coinfection in the Integrase Strand Transfer Inhibitor and Direct-Acting Antiviral Eras

BACKGROUND

People with human immunodeficiency virus (HIV) with and without hepatitis C virus (HCV) coinfection had poor outcomes after liver transplant (LT). Integrase strand transfer inhibitors (INSTIs) and direct-acting antivirals (DAAs) have changed the treatment landscape for HIV and HCV, respectively, but their impact on LT outcomes remains unclear.

METHODS

This retrospective analysis of adults with HIV monoinfection (n = 246) and HIV/HCV coinfection (n = 286) who received LT compared mortality in patients with HIV who received LT before versus after approval of INSTIs and in patients with HIV/HCV coinfection who received LT before versus after approval of DAAs. In secondary analysis, we compared the outcomes in the different eras with those of propensity score-matched control cohorts of LT recipients without HIV or HCV infection.

RESULTS

LT recipients with HIV monoinfection did not experience a significant improvement in survival between the pre-INSTI and INSTI recipients with HIV (adjusted hazard ratio [aHR], 0.70 [95% confidence interval {CI}, .36-1.34]). However, recipients with HIV/HCV coinfection in the DAA era had a 47% reduction (aHR, 0.53 [95% CI, .31-9.2] in 1-year mortality compared with coinfected recipients in the pre-DAA era. Compared to recipients without HIV or HCV, HIV-monoinfected recipients had higher mortality during the pre-INSTI era, but survival was comparable between groups during the INSTI era. HIV/HCV-coinfected recipients also experienced comparable survival during the DAA era compared to recipients without HCV or HIV.

CONCLUSIONS

Post-LT survival for people with HIV monoinfection and HIV/HCV coinfection has improved with the introduction of INSTI and DAA therapy, suggesting that LT has become safer in these populations.

Changing Landscape of Liver Transplantation in the Post-DAA and Contemporary ART Era

Combination anti-retroviral therapy has drastically improved solid organ transplantation outcomes in persons living with HIV. DAA therapy has led to the successful eradication of HCV. While recent data have suggested improvement in outcomes in HIV/HCV-coinfected liver transplant recipients, temporal trends in patient survival within pre- and post-DAA eras are yet to be elucidated. The UNOS database was utilized to identify deceased donor liver transplant recipients between 1 January 2000 and 30 September 2020 and stratify them by HIV and HCV infection status. A total of 85,730 patients met the inclusion criteria. One-year and five-year patient survival improved (93% and 80%, respectively) for all transplants performed post-2015. For HIV/HCV-coinfected recipients, survival improved significantly from 78% (pre-2015) to 92% (post-2015). Multivariate regression analyses identified advanced recipient age, Black race, diabetes mellitus and decompensated cirrhosis as risk factors associated with higher one-year mortality. Liver transplant outcomes in HIV/HCV-coinfected liver transplant recipients have significantly improved over the last quinquennium in the setting of the highly effective combination of ART and DAA therapy. The presence of HIV, HCV, HIV/HCV-coinfection and active HCV viremia at the time of transplant do not cause higher mortality risk in liver transplant recipients in the current era.

Liver resection of hepatocellular carcinoma in HIV-HCV co-infected patients: a retrospective case series

Introduction

Despite the effectiveness of new therapies and awareness campaigns, the number of seropositive patients is increasing every year. Recently, other causes of death, not directly related to HIV, have emerged, such as chronic liver disease. The risk of hepatocellular carcinoma (HCC) is seven times greater in HIV patients than in noninfected patients, and it is especially attributable to HCV infection. The aim of our study was to evaluate clinical outcomes of HCC in HIV-HCV co-infected patients after liver resection (LR).

Materials and methods

The current study was conducted on a prospective database and reviewed retrospectively. All consecutive patients with HCC treated by LR from January 2013 to March 2019 at the Luigi Sacco University Hospital in Milan were enrolled. We included patients older than 18 years of age with HCV-related HCC, and in this set of patients, we identified two groups based on the presence of HIV infection.

Results

We identified 16 patients with HCV infection and precisely five with HIV-HCV co-infection and eleven with HCV infection alone. All HIV patients were male against 72.7% in the non-HIV group (p = 0.509). All patients had optimal HIV virologic control and a normal CD4 T-cell count. The mean diagnosis-to-treatment interval was statistically different between the two groups (HIV versus non-HIV: 1.2 ± 0.55 months versus 2.39 ± 1.09 months, p = 0.039).

No other significant differences were found between HIV-HCV co-infected patients and HCV-infected patients. Long-term outcomes in terms of OS and RFS were similar between the two groups.

Conclusions

With a multidisciplinary approach and intensive support, LR can be a safe and efficacious procedure in HIV-HCV patients. For these reasons, we should not exclude potential patients merely on the basis of their HIV seropositivity.

LIVER TRANSPLANTATION IN HIV PATIENTS: A CASE SERIES FROM THE NORTHEAST REGION OF BRAZIL

BACKGROUND

The emergence of potent combined highly active antiretroviral therapy (ART) in 1996 changed the natural history of HIV infection, with a significant reduction in mortality due to opportunistic infections but increased morbidity due to chronic cardiovascular, hepatic, and renal diseases. In May 2016, a reference center for liver transplantation in the Northeast of Brazil performed the first liver transplantations (LT) in HIV patients, with five others until 2021.

METHODS

The criteria for selection of LT were good adherence and absence of resistance to ART, HIV viral load maximum suppression, T-CD4+ lymphocyte count of more than 100 cells/mm3, and absence of opportunistic infections in the last 6 months.

RESULTS

Six liver transplants were performed between May 2016 and May 2021, five men, with a mean age of 53.2 years, and one was a diabetic patient. All patients had access to grafts with short cold ischemia with a mean time of 5 hours and 39 minutes. The 4-month survival rate was 100%, with a range time of follow-up of 4-63 months (mean time of 31 months). The mean pre-transplant T-CD4+ lymphocyte count was 436 cells/mm3. The mean length of hospital stay after transplantation was 16.8 days. One patient presented precocious vena cava thrombosis; another had stenosis of cavocaval anastomosis leading to refractory ascites, renal failure and post-transplant graft dysfunction, and another presented stenosis of choledochal anastomosis. Immunosuppression and prophylaxis were used according to standard protocols, and there were no differences in the profile of infections or rejection after liver transplantation.

CONCLUSION

This case series documents good survival and usual transplant procedures for confirmed HIV cases.

Special Considerations in the Management of HIV and Viral Hepatitis Coinfections in Liver Transplantation

Modern therapies for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus have become so effective that patients treated for these conditions can have normal life-expectancies. Suitable livers for transplantation remain a scarce and valuable resource. As such, significant efforts have been made to expand donation criteria at many centers. This constant pressure, coupled with the increasing effectiveness of antiviral therapies, has meant that more and more patients infected with hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) may be considered appropriate donors in the right circumstances. Patients with these infections are also more likely to be considered appropriate transplantation recipients than in the past. The treatment of HBV, HCV, and HIV after liver transplantation (LT) can be challenging and complicated by viral coinfections. The various pharmaceutical agents used to treat these infections, as well as the immunosuppressants used post-LT must be carefully balanced for maximum efficacy, and to avoid resistance and drug–drug interactions.

HOPE in action: A prospective multicenter pilot study of liver transplantation from donors with HIV to recipients with HIV

Liver transplantation (LT) from donors-with-HIV to recipients-with-HIV (HIV D+/R+) is permitted under the HOPE Act. There are only three international single-case reports of HIV D+/R+ LT, each with limited follow-up. We performed a prospective multicenter pilot study comparing HIV D+/R+ to donors-without-HIV to recipients-with-HIV (HIV D-/R+) LT. We quantified patient survival, graft survival, rejection, serious adverse events (SAEs), human immunodeficiency virus (HIV) breakthrough, infections, and malignancies, using Cox and negative binomial regression with inverse probability of treatment weighting. Between March 2016-July 2019, there were 45 LTs (8 simultaneous liver-kidney) at 9 centers: 24 HIV D+/R+, 21 HIV D-/R+ (10 D- were false-positive). The median follow-up time was 23 months. Median recipient CD4 was 287 cells/µL with 100% on antiretroviral therapy; 56% were hepatitis C virus (HCV)-seropositive, 13% HCV-viremic. Weighted 1-year survival was 83.3% versus 100.0% in D+ versus D- groups (p = .04). There were no differences in one-year graft survival (96.0% vs. 100.0%), rejection (10.8% vs. 18.2%), HIV breakthrough (8% vs. 10%), or SAEs (all p > .05). HIV D+/R+ had more opportunistic infections, infectious hospitalizations, and cancer. In this multicenter pilot study of HIV D+/R+ LT, patient and graft survival were better than historical cohorts, however, a potential increase in infections and cancer merits further investigation.

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.

Nonviral liver disease is the leading indication for liver transplant in the United States in persons living with human immunodeficiency virus

We evaluated whether indications for liver transplantation (LT) have changed among people with/without human immunodeficiency virus (HIV) infection and compared LT outcomes and trends by HIV serostatus. LT recipients (2008-2018) from the United Network for Organ Sharing and Organ Procurement and Transplantation Network (UNOS/OPTN) were identifed. Among 62 195 LT recipients, 352 (0.6%) were HIV-infected. The proportion of HIV-infected patients increased over time (P trend = .001), as did the number of transplant centers performing LT for HIV-infected recipients; average annual percentage change of 9.2% (p < .001). Nonviral causes became the leading indication in 2015 for HIV-uninfected and in 2018 for HIV-infected (P trend < .001). Three-year cumulative patient survival rates were 77.5%, for HIV-infected and 84.6%, for HIV-uninfected (p = .15). Over time, graft and patient survival rates improved for both HIV-infected and uninfected (p < .001). Among HCV-infected LT recipients, 3-year patient survival rates were 72.5% for HIV-infected and 81.8% for HIV-uninfected (p = .02). However, in a subanalysis restricted to 2014-2018, differences in graft and patient survival by HIV serostatus were no longer observed (3-year patient survival rates were 81.2% for HIV-infected and 86.4% for HIV-uninfected, p = .34). In conclusion, in the United States, nonviral liver disease is now the leading indication for LT in HIV-infected patients, and posttransplant outcomes have improved over time.

Systematic Training of Liver Imaging Reporting and Data System Magnetic Resonance Imaging v2018 can Improve the Diagnosis of Hepatocellular Carcinoma for Different Radiologists

BACKGROUND AND AIMS

Liver imaging reporting and data system (LI-RADS) provides standardized lexicon and categorization for diagnosing hepatocellular carcinoma (HCC). However, there is limited knowledge about the effect of LI-RADS training. We prospectively explored whether the systematic training of LI-RADS v2018 on magnetic resonance imaging (MRI) can effectively improve the diagnostic performances of different radiologists for HCC.

METHODS

A total of 20 visiting radiologists and the multiparametric MRI of 70 hepatic observations in 61 patients with high risk of HCC were included in this study. The LI-RADS v2018 training procedure included three times of thematic lectures (each lasting for 2.5 h) given by a professor specialized in imaging diagnosis of liver, with an interval of a month. After each seminar, the radiologists had a month to adopt the algorithm into their daily work. The diagnostic performances and interobserver agreements of these radiologists adopting the algorithm for HCC diagnosis before and after training were compared.

RESULTS

A total of 20 radiologists (male/female, 12/8; with an average age of 36.75±4.99 years) were enrolled. After training, the interobserver agreements for the LI-RADS category for all radiologists (p=0.005) were increased. The sensitivity, specificity, positive predictive value, negative predictive value, and coincidence rate of all radiologists for HCC diagnosis before and after training were 43% vs. 54%, 86% vs. 88%, 74% vs. 81%, 62% vs. 67%, and 65% vs. 71%, respectively. The diagnostic performances of all radiologists (p<0.001) showed improvement after training.

CONCLUSIONS

The systematic training of LI-RADS can effectively improve the diagnostic performances of radiologists with different experiences for HCC.

HIV and Solid Organ Transplantation: A 15-Year Retrospective Audit at a Tertiary Australian Transplant Centre

BACKGROUND

The incidence of end-stage organ disease in people living with HIV (PLWH) is increasing, as people live longer due to potent, tolerable antiretroviral therapy. Consequently, the number of PLWH who would benefit from solid organ transplant (SOT) is rising. Solid organ transplantation experience in PLWH in Australia remains limited. The aim of this study was to retrospectively review the outcomes for SOT in PLWH in Victoria, Australia.

METHODS

A retrospective cohort study of PLWH undergoing SOT over a 15-year period was performed. Adult PLWH over 18 years of age were eligible and identified from the Victorian HIV Service database. Descriptive statistics were used to summarise baseline demographics and clinical data, and outcomes following SOT.

RESULTS

Nine virologically-suppressed PLWH underwent SOT from HIV-negative donors; 5 kidneys, 2 livers, and 2 bilateral sequential lung transplants. All patients were male, with a median age of 57.3 years (IQR 54.3-60.1), CD4 count of 485 (IQR 342-835) at transplantation, and comorbidities were common at baseline. After a median follow up of 3.9 years (IQR 2.7-7.6), 8 (89%) patents were alive, 7 (78%) had functioning grafts, though 5 (56%) experienced organ rejection. Infections were common. Two patients required modification to their antiretroviral therapy due to significant drug-drug interactions, prior to transplant, while 5 (56%) had modifications post-SOT. No patients experienced HIV virologic failure.

CONCLUSION

PLWH with end-stage organ disease experience good clinical and functional outcomes, and should be considered for SOT where indicated. However, multidisciplinary planning and care is essential to optomise care in this patient group. This article is protected by copyright. All rights reserved.

"Raising HOPE": Improved Outcomes for HIV/HCV-coinfected Liver Transplant Recipients in the Direct-acting Antiviral Era

The 2013 HIV Organ Policy Equity Act has increased liver transplantation (LT) in HIV⁺ patients; however, transplant centers may remain reluctant to perform LT in HIV/hepatitis C virus (HCV)-coinfected patients due to inferior outcomes. We aimed to assess how direct-acting antivirals (DAAs) have impacted HIV⁺/HCV⁺-coinfected LT recipient outcomes.

HIV and organ transplantation

PURPOSE OF REVIEW

This review summarizes the advances that have occurred over the past 2 years in organ transplantation in the setting of HIV.

RECENT FINDINGS

Although HIV+ organ transplantation is both safe and effective, recent studies show that HIV+ patients continue to experience barriers to transplantation. In the United States, the HOPE Act is not only expected to increase the donor pool for HIV+ transplant candidates, but to also allow for the use of donors with false-positive HIV+ tests, which had previously been banned under the US National Organ Transplant Act. More effective HCV treatment, increased experience with heart and lung transplantation and the potential for increased organ availability with the inclusion of HIV+ organ donors have provided for significant advances in the care of these patients.

SUMMARY

There continues to be progress in the field of organ transplantation in persons living with HIV. Future efforts should continue aiming to limit barriers to transplantation and improving the understanding of immunologic derangements seen in transplant recipients with HIV infection.