Solid organ transplantation in the HIV-infected patient

Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation

Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.

First experience of liver transplantation for HIV-positive patients in Russia

The article presents the results of liver transplantation in five HIV-infected recipients with irreversible liver damage. It is shown that four of them survived in the long-term period and are observed in a stable condition, and the only death in the recipient was not related to the HIV infection. The experience in the treatment of these patients was summarized. Analysis of the first results of liver transplantation in HIV-infection in Russia shows its validity and clinical efficacy. The only lethal case is connected with the initial extremely grave condition of the recipient and his age. Two cases of surgical traumatism, lack of consistent vaccination in the preoperative period, as well as lack of patients with hepatocellular cancer, small number of observations are obvious drawbacks of our first experience and should be corrected in the future. The success of a complex and multidisciplinary program of organ transplantation in HIV infection is impossible without participation of HIV-infectionists in the transplantation team.

Bictegravir/emtricitabine/tenofovir alafenamide combination in the management of kidney transplant patients with HIV receiving immunosuppressants

We report here a drug-drug interaction with tacrolimus in a HIV-positive patient with renal transplant, after switch from highly active antiretroviral therapy with boosted protease inhibitors to the combination bictegravir/emtricitabine/tenofovir alafenamide. Although the tacrolimus doses were adapted to take account of the pharmacokinetic interactions with protease inhibitors, a tacrolimus overdosage occurred in the patient nonetheless. Through this case report, we highlight the need to consider a sufficient timeframe of withdrawal of protease inhibitors, which induce a prolonged drug-drug interaction with tacrolimus. To conclude, we purport that the combination bictegravir/emtricitabine/tenofovir alafenamide could be an attractive alternative in the context of transplantation provided a discontinuation of boosted protease inhibitors for more than 48 hours before introducing tacrolimus.

Infection in Kidney Transplant Recipients

In organ transplant recipients, impaired inflammatory responses suppress the clinical and radiologic findings of infection. The possible etiologies of infection are diverse, ranging from common bacterial and viral pathogens that affect the entire community to opportunistic pathogens that cause invasive disease only in immunocompromised hosts. Antimicrobial therapies required to treat established infection are often complex, with accompanying risks for drug toxicities and drug interactions with the immunosuppressive agents used to maintain graft function. Rapid and specific diagnosis is essential for successful therapy. The risk of serious infections in the organ transplant patient is largely determined by the interaction between two factors: the patient’s epidemiologic exposures and the patient’s net state of immunosuppression. The epidemiology of infection includes environmental exposures and nosocomial infections, organisms derived from donor tissues, and latent infections from the recipient activated with immunosuppression. The net state of immune suppression is a conceptual framework that measures those factors contributing to risk for infection: the dose, duration, and temporal sequence of immunosuppressive drugs; the presence of foreign bodies or injuries to mucocutaneous barriers; neutropenia; metabolic abnormalities including diabetes; devitalized tissues, hematomas, or effusions postsurgery; and infection with immunomodulating viruses. Multiple factors are present in each host. A timeline exists to aid in the development of a differential diagnosis for infection. The timeline for each patient is altered by changes in prophylaxis and immunosuppressive drugs. For common infections, new microbiologic assays, often nucleic acid based, are useful in the diagnosis and management of opportunistic infections.

Transplant advocacy in the era of the human immunodeficiency virus organ policy equity act

In 2013, the Human Immunodeficiency Virus Organ Policy Equity (HOPE) Act was passed to permit the conduct of research on the transplantation of organs from donors infected with human immunodeficiency virus (HIV) into recipients who are HIV-positive. The HOPE Act workshop had many objectives including the discussion of the ethical issues involved in HIV-positive to HIV-positive transplantation, the informed consent process, and the role of independent advocates in the context of HIV to HIV transplantation. As of 2018, 22 transplant hospitals are approved, or undergoing approval, to perform HIV-positive to HIV-positive transplant surgeries, and this number is expected to grow. This study aims to: (i) briefly review the history and research of HIV+ transplantation prior to the HOPE Act, (ii) describe the ethical principles supporting the HOPE Act, (iii) characterize the informed consent process, and (iv) provide guidance regarding the role of independent advocates in the context of HIV-positive to HIV-positive transplantation.

Infection in Kidney Transplantation

Infection is an important cause of morbidity and mortality after kidney transplantation. It has been estimated that 70% of kidney transplant recipients will experience an infection episode within the first 3 years after transplantation (Dharnidharka et al. 2007). After cardiovascular disease, infection is the second leading cause of death in recipients with allograft function (Snyder et al. 2009). The immunosuppressive therapy required to prevent organ rejection places the kidney transplant recipient at increased risk for donor-derived, nosocomial, and community-acquired infections as well as reactivation of latent pathogens. Pretransplant screening, immunizations, and optimal antibacterial and antiviral prophylaxis can help to reduce the impact of infection. Awareness of the approach to infection in the transplant recipient including diagnostic and management strategies is essential to optimizing outcomes.

Survival Benefit of Kidney Transplantation in HIV-infected Patients

OBJECTIVE

To determine the survival benefit of kidney transplantation in human immunodeficiency virus (HIV)-infected patients with end-stage renal disease (ESRD).

SUMMARY BACKGROUND DATA

Although kidney transplantation (KT) has emerged as a viable option for select HIV-infected patients, concerns have been raised that risks of KT in HIV-infected patients are higher than those in their HIV-negative counterparts. Despite these increased risks, KT may provide survival benefit for the HIV-infected patient with ESRD, yet this important clinical question remains unanswered.

METHODS

Data from the Scientific Registry of Transplant Recipients were linked to IMS pharmacy fills (January 1, 2001 to October 1, 2012) to identify and study 1431 HIV-infected KT candidates from the first point of active status on the waiting list. Time-dependent Cox regression was used to establish a counterfactual framework for estimating survival benefit of KT.

RESULTS

Adjusted relative risk (aRR) of mortality at 5 years was 79% lower after KT compared with dialysis (aRR 0.21; 95% CI 0.10-0.42; P <0.001), and statistically significant survival benefit was achieved by 194 days of KT. Among patients coinfected with hepatitis C, aRR of mortality at 5 years was 91% lower after KT compared with dialysis (aRR 0.09; 95% CI 0.02-0.46; P < 0.004); however, statistically significant survival benefit was not achieved until 392 days after KT.

CONCLUSIONS

Evidence suggests that for HIV-infected ESRD patients, KT is associated with a significant survival benefit compared with remaining on dialysis.

Kidney Transplantation in HIV-Infected Recipients: Therapeutic Strategy and Outcomes in Monocentric Experience

BACKGROUND

In Human immunodeficiency virus (HIV)-positive patients undergoing kidney transplantation, outcomes and immunosuppression (IS) protocol are not yet established due to infectious and neoplastic risks as well as to pharmacokinetic interactions with antiretroviral therapy (TARV).

METHODS

We report a retrospective, 1-center study on 18 HIV+ patients undergoing, between October 2007 and September 2015, kidney transplantation (13 cases) or combined kidney-liver transplant (5 cases). Inclusion criteria for transplant were based on the Italian National Transplant Center protocol. IS regimen was based on quick tapering of steroids and the use of mTOR inhibitors (mTORi) with low dose of calcineurin inhibitors (CNI). In the early post-transplant period, TARV was based on enfuvirtide, raltegravir, plus 1 or more nucleoside analogues.

RESULTS

In a mean follow-up of 3.1 years, patient survival rate at 1 and 3 years was, respectively, 86.6% and 84.6%, whereas graft survival was 81.2% and 78.6%. Cumulative rejection rate was 20.0% and 26.6% (1- and 3-year results). Median eGFR (MDRD) was 58.8 mL/min and 51.9 mL/min at 1 and 3 years. We had 9 cases of clinically relevant infections (2 Pneumocystis jirovecii pneumonia, 1 pulmonary aspergillosis, 2 severe sepsis, and 4 HCV reactivation) as well as 1 case (5.5%) of HIV reactivation.

CONCLUSIONS

IS therapy based on mTORi and low CNI dose ensures good graft survival, low rate of acute rejection, limited drug toxicity, and control of HIV disease. TARV has no significant interaction with IS therapy.

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.

Integrase strand transferase inhibitors: the preferred antiretroviral regimen in HIV-positive renal transplantation

In the era of antiretroviral therapy, people living with HIV/AIDS live longer and are subject to co-morbidities that affect the general population, such as chronic kidney disease. An increasing number of people living with HIV/AIDS with end-stage renal disease are candidates for renal transplantation. Prior experience demonstrated that HIV-positive renal transplant recipients had acceptable survival but graft survival was decreased and rejection rates were increased, possibly due to suboptimal management of immunosuppressive medications in the face of drug interactions with antiretroviral therapy, particularly protease inhibitors and non-nucleoside reverse transcriptase inhibitors. Integrase strand transferase inhibitors are advantageous since they avoid drug-drug interactions with immunosuppressive drugs such as calcineurin inhibitors. We report clinical outcomes of 12 HIV-positive patients who underwent 13 kidney transplantations at our institution between 2000 and 2015. Cumulative survival was 75%, one-year and three-year survival were 100% and 63%. Integrase strand transferase inhibitor-based regimens were used in nine patients, of which eight survived. In patients on integrase strand transferase inhibitor, there was 100% graft survival and two had allograft rejection. In contrast, graft failure occurred in three patients on non-integrase strand transferase inhibitor-based regimens. Based on our study findings and on previously published data, we conclude that integrase strand transferase inhibitor-based therapy, preferably instituted prior to transplantation, is the preferred antiretroviral regimen in HIV-positive renal transplantation.

Long-term Outcomes After Liver Transplantation Among Human Immunodeficiency Virus-Infected Recipients

BACKGROUND

Early outcomes after human immunodeficiency virus (HIV) + liver transplantation (LT) are encouraging, but data are lacking regarding long-term outcomes and comparisons with matched HIV- patients.

METHODS

We examined outcomes among 180 HIV+ LT, and compared outcomes to matched HIV- counterfactuals (Scientific Registry of Transplant Recipients 2002-2011). Iterative expanding radius matching (1:10) on recipient age, race, body mass index, hepatitis C virus (HCV), model for end-stage liver disease score, and acute rejection; and donor age and race, cold ischemia time, and year of transplant. Patient survival and graft survival were estimated using Kaplan-Meier methodology and compared using log-rank and Cox proportional hazards. Subgroup analyses were performed by transplant era (early: 2002-2007 vs. modern: 2008-2011) and HCV infection status.

RESULTS

Compared to matched HIV- controls, HIV+ LT recipients had a 1.68-fold increased risk for death (adjusted hazard ratio [aHR], 1.68, 95% confidence interval [95% CI], 1.28-2.20; P < 0.001), and a 1.70-fold increased risk for graft loss (aHR, 1.70; 95% CI, 1.31-2.20; P < 0.001). These differences persisted independent of HCV infection status. However, in the modern transplant era risk for death (aHR, 1.11; 95% CI, 0.52-2.35; P = 0.79) and graft loss (aHR, 0.89; 95% CI, 0.42-1.88; P = 0.77) were similar between monoinfected and uninfected LT recipients. In contrast, independent of transplant era, coinfected LT recipients had increased risk for death (aHR, 2.24; 95% CI, 1.43-3.53; P < 0.001) and graft loss (aHR, 2.07; 95% CI, 1.33-3.22; P = 0.001) compared to HCV+ alone LT recipients.

CONCLUSIONS

These results suggest that outcomes among monoinfected HIV+ LT recipients have improved over time. However, outcomes among HIV+ LT recipients coinfected with HCV remain concerning and motivate future survival benefit studies.

Systematic computer tomographic scans 7 days after liver transplantation surgery can lower rates of repeat-transplantation due to arterial complications

Arterial complications are a major cause of graft lost after liver transplantation (LT). The aim of our study was to assess the clinical impact of systematic early postoperative injected computed tomographic (CT) scans after LT rather than its performance on demand in the event of abnormalities. Two series of consecutive transplantation patients in different periods (1997-1999, 231 patients versus 2008-2010, 250 patients) were analyzed. During the first period, an injected CT scan was only performed in the event of clinical, biological, or ultrasound abnormalities revealed by tests performed daily during the first week after surgery. During the second period, in addition to standard follow-up examination, an injected CT scan was performed systematically at approximately postoperative day 7. During the first (versus the more recent) period, both recipients (whose ages were 46 ± 13 years versus 50 ± 12 years; P = .004) and donors (whose ages were 42 ± 17 versus 52 ± 17 years; P = .0001) were younger and end-stage liver disease was more common (34% versus 12%; P = .0001), but hepatocellular carcinoma (7% vs 26%; P = .0001) and retransplantation (2% versus 7%; P = .01) were less frequent. Postoperative mortality was higher during the first period (14% versus 4%; P = .0003). The incidence of early arterial thrombosis (<1 month) was similar (1.3% versus 1.6%; P = .78), but that of arterial stenosis was higher with a systematic CT scan (1.7 versus 4.4; P = .07). As a consequence of the early detection and treatment of arterial abnormalities, the repeat LT rate due to late arterial thrombosis was nil in the second period and 2.1% (5/231) in the first period. In conclusion, a systematic CT angiogram at the end of the first postoperative week reduced retransplantation rates due to late hepatic artery thrombosis by detecting patients at risk who required specific treatment.

Renal transplantation in human immunodeficiency virus-positive patients: a report of four cases

INTRODUCTION

Renal transplantation (RT) in patients infected with human immunodeficiency virus (HIV) has significantly improved under the advent of combined antiretroviral therapy (cART). The authors describe their experience in RT in patients with HIV from September 2010 to June 2013.

CASES REPORT

Four patients underwent transplantation (3 with HIV-1 and 1 with HIV-2), three patients were male, and one was black. None were coinfected with hepatitis B virus (HBV) or hepatitis C virus (HCV). Etiology of kidney disease was HIV-associated nephropathy (2 patients), immunoglobulin (Ig)A nephropathy, and unknown. Average age at RT was 51 (range, 41-63) years. No patient was of high immunologic risk. Immunosuppression consisted of basiliximab for induction and prednisolone, tacrolimus (TAC), and mycophenolate mofetil for maintenance. TAC levels varied considerably in the early days (8.5-46 ng/mL), requiring major adjustments in TAC dose. Only the HIV-2 patient had delayed graft function. The follow-up of patients with HIV-1 was 37, 19, and 16 months, and 3 months for the HIV-2 patient. CD4+ T cells decreased in the early days after transplantation with subsequent improvement, along with persistent virological suppression. In the HIV-1 group there were no major infectious, cardiovascular, or neoplastic complications. Nevertheless, the HIV-2 patient died 3 months after RT due to H1N1 pneumonia complicated by pulmonary aspergillosis. Average estimated (CKD- EPI) glomerular filtration rate (eGFR) at 6 months was 85.6 mL/min/1.73 m(2).

CONCLUSION

Besides the difficulty in adjusting calcineurin inhibitors levels due to its interaction with antiretroviral therapy, namely with protease inhibitors, no patient had acute rejection. Furthermore, all patients presented an excellent control of viro-immunologic parameters. At the last follow-up neither cardiovascular events nor neoplastic complications were observed. Our results highlight the favorable outcome of RT in HIV-1-infected patients. The HIV-2 patient died due to severe infection, and the clinical management and potential benefit of RT in HIV-2-infected patients needs further study.

Thirty-day postoperative mortality among individuals with HIV infection receiving antiretroviral therapy and procedure-matched, uninfected comparators

IMPORTANCE

Antiretroviral therapy (ART) has converted human immunodeficiency virus (HIV) infection into a chronic condition, and patients now undergo a variety of surgical procedures, but current surgical outcomes are inadequately characterized.

OBJECTIVE

To compare 30-day postoperative mortality in patients with HIV infection receiving ART with the rates in uninfected individuals.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of nationwide electronic medical record data from the US Veterans Health Administration Healthcare System, October 1, 1996, to September 30, 2010. Common inpatient surgical procedures were grouped using the Healthcare Cost and Utilization Project Clinical Classification System to match HIV-infected and uninfected patients in a 1:2 ratio. Data on 1641 patients with HIV infection receiving combination ART who were undergoing inpatient surgery were compared with data on 3282 procedure-matched, uninfected comparators. Poisson regression models of 30-day postoperative mortality were adjusted for procedure year, age, Charlson Comorbidity Index score, hemoglobin level, albumin level, HIV infection, CD4 cell count, and HIV-1 RNA level.

MAIN OUTCOMES AND MEASURES

All-cause 30-day postoperative mortality.

RESULTS

The most common procedures in both groups were cholecystectomy (10.5%), hip arthroplasty (10.5%), spine surgery (9.8%), herniorrhaphy (7.4%), and coronary artery bypass grafting (7.0%). In patients with HIV infection, CD4 cell distributions were 80.0% with 200/μL or more, 16.3% with 50/μL to 199/μL, and 3.7% with less than 50/μL; 74.1% of patients with HIV infection had undetectable HIV-1 RNA. Human immunodeficiency virus infection was associated with higher 30-day postoperative mortality compared with the mortality in uninfected patients (3.4% [56 patients]) vs 1.6% [53]); incidence rate ratio [IRR], 2.11; 95% CI, 1.41-3.17; P < .001). CD4 cell count was inversely associated with mortality, but HIV-1 RNA provided no additional information. After adjustment, patients with HIV infection had increased mortality compared with uninfected patients at all CD4 cell count strata (≥500/μL: IRR, 1.92; 95% CI, 1.02-3.60; P = .04; 200-499/μL: IRR, 1.89; 95% CI, 1.20-2.98; P = .01; 50-199/μL: IRR, 2.66; 95% CI, 1.29-5.47; P = .01; and <50/μL: IRR, 6.21; 95% CI, 3.55-10.85; P < .001). Hypoalbuminemia (IRR, 4.35; 95% CI, 2.78-6.81; P < .001) and age in decades (IRR, 1.47; 95% CI, 1.23-1.76; P < .001) were also strongly associated with mortality.

CONCLUSIONS AND RELEVANCE

Current postoperative mortality rates among individuals with HIV infection who are receiving ART are low and are influenced as much by hypoalbuminemia and age as by CD4 cell status. Human immunodeficiency virus infection and CD4 cell count are only 2 of many factors associated with surgical outcomes that should be incorporated into surgical decision making.

A National Study of Outcomes among HIV-Infected Kidney Transplant Recipients

Kidney transplantation is a viable treatment for select patients with HIV and ESRD, but data are lacking regarding long-term outcomes and comparisons with appropriately matched HIV-negative patients. We analyzed data from the Scientific Registry of Transplant Recipients (SRTR; 2002-2011): 510 adult kidney transplant recipients with HIV (median follow-up, 3.8 years) matched 1:10 to HIV-negative controls. Compared with HIV-negative controls, HIV-infected recipients had significantly lower 5-year (75.3% versus 69.2%) and 10-year (54.4% versus 49.8%) post-transplant graft survival (GS) (hazard ratio [HR], 1.37; 95% confidence interval [95% CI], 1.15 to 1.64; P<0.001) that persisted when censoring for death (HR, 1.43; 95% CI, 1.12 to 1.84; P=0.005). However, compared with HIV-negative/hepatitis C virus (HCV)-negative controls, HIV monoinfected recipients had similar 5-year and 10-year GS, whereas HIV/HCV coinfected recipients had worse GS (5-year: 64.0% versus 52.0%, P=0.02; 10-year: 36.2% versus 27.0%, P=0.004 [HR, 1.38; 95% CI, 1.08 to 1.77; P=0.01]). Patient survival (PS) among HIV-infected recipients was 83.5% at 5 years and 51.6% at 10 years and was significantly lower than PS among HIV-negative controls (HR, 1.34; 95% CI, 1.08 to 1.68; P<0.01). However, PS was similar for HIV monoinfected recipients and HIV-negative/HCV-negative controls at both times. HIV/HCV coinfected recipients had worse PS compared with HIV-negative/HCV-infected controls (5-year: 67.0% versus 78.6%, P=0.007; 10-year: 29.3% versus 56.23%, P=0.002 [HR, 1.57; 95% CI, 1.11 to 2.22; P=0.01]). In conclusion, HIV-negative and HIV monoinfected kidney transplant recipients had similar GS and PS, whereas HIV/HCV coinfected recipients had worse outcomes. Although encouraging, these results suggest caution in transplanting coinfected patients.

Clinical practice guideline for the management of chronic kidney disease in patients infected with HIV: 2014 update by the HIV Medicine Association of the Infectious Diseases Society of America

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

[Contraindications to lung transplantation: evolving limits?]

In France, the higher frequency of pulmonary sample in organ donors and the enhancement of surgical and perioperative life support techniques, have increased the number procedures and the short term prognosis of lung transplantation (LT). In this setting, the classical contraindications of LT need to be reconsidered. In this article, some of the classical contraindication of LT are confronted to the experience acquired in other solid organ transplantations or from some LT centers. Specific situations such as LT in patients with previous cancer, HIV infection, viral hepatitis, nutritional disorders, acutely ill LT candidates and aging candidates are addressed. Surgical contraindications are not reviewed.

Multicenter italian experience in liver transplantation for hepatocellular carcinoma in HIV-infected patients

BACKGROUND

The aim of our work is to assess the clinical outcomes of liver transplantation (LT) for hepatocellular carcinoma (HCC) in HIV-coinfected patients. This is a multicenter study involving three Italian transplant centers in northern Italy: University of Modena, University of Bologna, and University of Udine.

PATIENTS AND METHODS

We compared 30 HIV-positive patients affected by HCC who underwent LT with 125 HIV-uninfected patients who received the same treatment from September 2004 to June 2009. At listing, there were no differences between HIV-infected and -uninfected patients regarding HCC features. Patients outside the University of California, San Francisco criteria (UCSF) were considered eligible for LT if a down-staging program permitted a reduction of tumor burden.

RESULTS

HIV-infected patients were younger, they were more frequently anti-HCV positive, and a higher number of HIV-infected patients presented a coinfection HBV-HCV. Pre-LT treatments (liver resection and or locoregional treatments) were similar between the two groups. Histological characteristics of the tumor were similar in patients with and without HIV infection. No differences were observed in terms of overall survival and HCC recurrence rates.

CONCLUSION

LT for HCC is a feasible procedure and the presence of HIV does not particularly affect the post-LT outcome.

Common infections in kidney transplant recipients

Infections are a major cause of morbidity and mortality in kidney transplant recipients. To some extent, these may be preventable. Careful pretransplant screening, immunization, and post-transplant prophylactic antimicrobials may all reduce the risk for post-transplant infection. However, because transplant recipients may not manifest typical signs and symptoms of infection, diagnoses may be confounded. Furthermore, treatment regimens may be complicated by drug interactions and the need to maintain immunosuppression to avoid allograft rejection. This article reviews common post-transplant infections, including prophylactic, diagnostic, and treatment strategies, providing guidance regarding care of kidney transplant patients with infection.

Disparities in rates of spine surgery for degenerative spine disease between HIV-infected and uninfected veterans

STUDY DESIGN

Retrospective analysis of nationwide Veterans Health Administration clinical and administrative data.

OBJECTIVE

Examine the association between HIV infection and the rate of spine surgery for degenerative spine disease.

SUMMARY OF BACKGROUND DATA

Combination antiretroviral therapy has prolonged survival in HIV-infected patients, increasing the prevalence of chronic conditions such as degenerative spine disease that may require spine surgery.

METHODS

We studied all HIV-infected patients under care in the Veterans Health Administration from 1996 to 2008 (n = 40,038) and uninfected comparator patients (n = 79,039) matched on age, sex, race, year, and geographic region. The primary outcome was spine surgery for degenerative spine disease, defined by International Classification of Diseases, Ninth Revision procedure and diagnosis codes. We used a multivariate Poisson regression to model spine surgery rates by HIV infection status, adjusting for factors that might affect suitability for surgery (demographics, year, comorbidities, body mass index, combination antiretroviral therapy, and laboratory values).

RESULTS

Two hundred twenty-eight HIV-infected and 784 uninfected patients underwent spine surgery for degenerative spine disease during 700,731 patient-years of follow-up (1.44 surgeries per 1000 patient-years). The most common procedures were spinal decompression (50%) and decompression and fusion (33%); the most common surgical sites were the lumbosacral (50%) and cervical (40%) spine. Adjusted rates of surgery were lower for HIV-infected patients (0.86 per 1000 patient-years of follow-up) than for uninfected patients (1.41 per 1000 patient-years; incidence rate ratio 0.61, 95% confidence interval: 0.51-0.74, P < 0.001). Among HIV-infected patients, there was a trend toward lower rates of spine surgery in patients with detectable viral load levels (incidence rate ratio 0.76, 95% confidence interval: 0.55-1.05, P = 0.099).

CONCLUSION

In the Veterans Health Administration, HIV-infected patients experience significantly reduced rates of surgery for degenerative spine disease. Possible explanations include disease prevalence, emphasis on treatment of nonspine HIV-related symptoms, surgical referral patterns, impact of HIV on surgery risk-benefit ratio, patient preferences, and surgeon bias.

Liver transplantation in HCV/HIV positive patients

Since the introduction of highly active antiretroviral therapy (HAART) in 1996 for human immunodeficiency virus (HIV)-infected patients, the incidence of liver diseases secondary to co-infection with hepatitis C has increased. Although data on the outcome of liver transplantation in HIV-infected recipients is limited, the overall results to date seem to be comparable to that in non-HIV-infected recipients. Liver transplant centers are now accepting HIV-infected individuals as organ recipients. Post-transplantation HIV replication is controlled by HAART. Hepatitis C re-infection of the liver graft, however, remains an important problem because cirrhotic changes of the liver graft may be more rapid in HIV-infected recipients. Interactions between the HAART components and immunosuppressive drugs influence drug metabolism and therefore meticulous monitoring of drug blood level concentrations is required. The risk of opportunistic infection in HIV-positive transplant patients seems to be similar to that in HIV-negative transplant recipients.