Neil Canavan

December 05, 2011

December 5, 2011 (San Francisco, California) — Patients coinfected with hepatitis C virus (HCV) and HIV have only a 55% chance of survival 5 years after liver transplantation, according to results from a study performed at a French transplant center and reported here at The Liver Meeting 2011: American Association for the Study of Liver Diseases 62nd Annual Meeting. The study authors concede that improvements in care might depend on the near-term availability of new HCV therapies.

Liver disease progression to cirrhosis is rapid in HIV-infected patients, and liver transplantation is now an accepted therapeutic option for those with end-stage liver disease. "However, everyone knows that the mortality in HIV/HCV coinfected patients is very high," said principal investigator Jean-Charles Duclos-Vallée, MD, Centre Hépato-Biliaire, Hôpital Paul-Brousse, Villejuif, France. "A paper from 2005 puts the figure at just 25% 5 years after the first episode of decompensation, compared with 44% for HCV patients without HIV."

This reference aside, there are limited data overall regarding the survival of coinfected patients who undergo liver transplantation, he said. However, the increasing frequency of HIV-positive patients undergoing transplantation and the severity of recurrence of HCV infection in the liver grafts in transplanted patients is of growing concern.

Dr. Duclos-Valle and colleagues looked at survival rates and the degree of recurrence of HCV infection in 105 transplant patients at their center. The patient cohort was 83% male, 61% had HCV genotype 1, median MELD score was 16.0, and waiting time to transplantation was 4.9 months. All patients were using highly active antiretroviral therapy (HAART) at the time of transplantation. Reasons for transplant included HCV-related cirrhosis (56%), hepatocellular carcinoma (HCC; 19%), hepatitis B virus (HBV)-related cirrhosis (7.6%), HBV/HCV-related cirrhosis (4.7%), and other (14%).

"The overall survival rate for the entire cohort was 55% at 5 years posttransplant," said Dr. Duclos-Valle.

The 5-year survival rate for patients with HCV-related cirrhosis was 45%, with HCC was 49%, and with HBV-related cirrhosis was 100%. Nine patients have undergone retransplantation. Of the 40 deaths, 20 were due to HCV recurrence, 5 were due to HCC, 5 were due to sepsis, and 2 were due to myocardial infarction; the remaining patients died for other reasons.

After transplantation, anti-HCV therapy (pegylated interferon alfa-2a plus ribavirin) was given to 36 of 58 patients who had a recurrence of HCV infection in the new liver graft. The response rates were as follows: no response in 24 patients, partial response in 6, and sustained viral response in 6.

"For response to treatment after recurrence, we had [a sustained viral response] of 16.6%, with 64% nonresponders and 1 relapse," said Dr. Duclos-Valle. Given the dismal survival outcomes 5 years after transplantation and the less-than-optimal response rates to retreatment after HCV recurrence, Dr. Duclos-Valle said he is doubly concerned. Transplant organ resources are already strained, and with the success of HAART treatment, the number of HIV-infected individuals that will require transplantation in the future will only increase.

Race Against Demographics

"We are going to be seeing more of these patients," noted Jay H. Hoofnagle, MD, director of the Liver Disease Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, in Bethesda, Maryland. "They're living longer so they're going to have other health issues."

Dr. Hoofnagle said he is seeing an increase in complications from chronic conditions such as heart disease. "As HAART therapy extends lives, you're going to see these complications. That is particularly true with hepatitis C because of the common modes of transmission."

Dr. Hoofnagle is optimistic, however, about the overall prognosis for the situation. "The treatments for hepatitis C are improving so fast that what looks bad now is just going to improve with new drugs. This will be particularly helpful for the coinfected group, when you get the chance to get these patients away from interferon, which is very hard to take." Dr. Hoofnagle expects to see critical improvements in HCV treatment within the next 5 years.

Dr. Duclos-Valle and Dr. Hoofnagle have disclosed no relevant financial relationships.

The Liver Meeting 2011: American Association for the Study of Liver Diseases (AASLD) 62nd Annual Meeting. Abstract 4. Presented November 6, 2011.

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