Liver Transplantation for HIV/HCV Coinfection

Where Is the Controversy?

Emily Dannhorn; James P O'Beirne

Disclosures

Future Virology. 2013;8(7):639-648. 

In This Article

Abstract and Introduction

Abstract

Liver transplantation (LT) is an accepted mode of treatment for patients with chronic liver disease. Historically, patients with HIV were excluded from LT programs, but with the introduction of highly effective antiretroviral regimens, HIV is no longer a contraindication. LT outcomes for some liver diseases in HIV-positive patients are equivalent to those observed in non-HIV-positive patients. This is not the case for patients coinfected with HIV and HCV, however, where results at 5 years have led to suggestions that LT for coinfection should be abandoned. This article examines the role of LT for HIV/HCV and identifies groups of patients where transplantation is associated with good outcomes. We believe that the application of existing knowledge to patient selection and organ allocation could improve outcomes further, and with the advent of directly acting antivirals for HCV, LT for HIV/HCV coinfection will no longer be controversial.

Introduction

Since the introduction of combined antiretroviral therapy (cART) in the mid-1990s, HIV has been a manageable disease for most, with an expected near-normal life expectancy.[1] Comorbidities, especially liver disease, are therefore of increasing clinical relevance, and chronic liver disease has become a leading cause of death in patients with HIV.[2,3] Liver transplantation (LT) was first performed in 1963 and has evolved from an experimental procedure to become the cornerstone of management of advanced end-stage liver disease and complications of cirrhosis.[4] Initially HIV infection was considered to be a contraindication to LT, but with the advent of cART, patients with HIV can now access LT and in most cases have outcomes similar to, if not better than, patients without HIV.[5] In HIV-infected individuals, HCV is a common cause of cirrhosis and there is therefore a need for LT in many individuals for this indication. Recently, however, due to poor results reported in the literature, the role of LT in patients coinfected with HIV and HCV has been called into question and some have suggested that LT for this indication should be abandoned.[6]

This is a regrettable situation given that LT is a surgical technique and specialty that has evolved through innovation and constant refinement of indications based on rigorous examination of outcomes. Many of the developments made in the field of LT were only made possible through continued experience gained from pioneering procedures. Without pushing these boundaries, we would not know whom to transplant (and whom not to transplant) with hepatocellular carcinoma (HCC) and acute liver failure, as well as others. To abandon LT for HIV/HCV-coinfected patients is, we believe, premature. In this article we hope to show that, using knowledge gained from recent experience, it is possible to select those coinfected patients who will do well, and with the advent of the directly acting antivirals (DAAs) for HCV, we hope to show not only that HIV/HCV coinfection has the potential to become a routine indication for LT, but also one with excellent results in the near future.

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