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

LT Outcomes in HIV/HCV Coinfection: From Past to Present

As previously mentioned, HIV was considered to be a contraindication to LT in the pre-cART era. However with the increasing realization that HIV could be controlled, and experience in a small number of patients who had been transplanted and then subsequently found to be seropositive, the issue of LT in HIV-positive recipients was revisited. The King's College Group published one of the earliest series in 2001.[29] This small series of five patients was one of the first to examine outcomes of patients known to be HIV-positive at the time of LT. Of the five patients described, three were coinfected with HCV. ART was used in all patients, three pre-LT and two post-LT. The outcomes for the HCV patients were poor, with all three patients dying within 16 months of LT from a severe form of HCV recurrence in the graft (fibrosing cholestatic hepatitis). It is notable that two patients received antiviral treatment with interferon and ribavarin, one receiving treatment as early as 2 weeks, and all the HCV patients had at least one episode of rejection. This report does not describe in detail the interaction between the cART and immunosuppressive drugs, but it is interesting that at the time of death the CD4 count ranged from 5 to 87 cells/mm3, suggesting that there had been some loss of HIV control during the postoperative period, perhaps due to difficulty with drug interactions. The non-HCV-infected patients in the study did extremely well and remained free from complications related to the liver graft or HIV. This finding was considered encouraging and more centers began to transplant HIV-positive patients, especially after publication of guidelines in the UK ( Box 1 ).[30]

Shortly following the publication of the initial series from King's, Ragni et al. published their experience of transplantation in HIV-infected individuals.[31] They were able to show cumulative survival among 24 HIV-positive HAART recipients that was similar to age- and race-matched HIV-negative recipients. At 12, 24 and 36 months after LT, respective estimated survival rates were 87, 73 and 73% among HIV-positive patients and 87, 82 and 78% among HIV-negative patients, confirming that transplantation was feasible and effective in HIV infection. Similar to the King's group they found that survival in patients with HIV/HCV coinfection was significantly lower than in HCV controls.

A number of retrospective and prospective series have now confirmed that outcomes in HIV/HCV coinfection are inferior to other indications, especially under longer periods of follow-up.

Table 1 summarizes patient survival at set intervals as reported in larger series in the cART era to date. One striking feature of the series published so far is a wide variation in short- and medium-term outcomes, especially in smaller series. This raises the question as to whether there is significant variation in center practice that is impacting on outcome. The more recent series involved larger number of patients enrolled in multiple centers prospectively, thus allowing more detailed analysis of variables that may be associated with outcome.

processing....