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

Future Perspective

There is no doubt that the current medium- to long-term outcomes of LT in coinfected patients are unacceptable. To not use the published data to change the selection, allocation criteria and post-transplant management of coinfected patients runs the risk of this indication being abandoned due to the competing needs of non-coinfected patients who may expect better post-LT outcomes. What needs to be done? Firstly, using the published data it is already possible to identify a subgroup of patients who will do well with LT (Box 3), especially in an experienced center. LT in these patients should not be controversial and outcomes can be expected to be excellent. However, patients with this phenotype are not prioritized effectively within organ allocation systems designed around liver disease severity, and this suggests that coinfected patients should have a different allocation system or be given priority based on MELD combined with other criteria such as BMI. These changes will be hard to enact in the current era of donor shortage and are perhaps unachievable. A more realistic aim is to restrict LT in coinfected patients with renal dysfunction or where the BMI is less than 21. This simple change will improve outcome. Early referral to a LT center is key to ensuring timely access to LT prior to the development of these complications. As previously mentioned, current organ allocation systems do not necessarily favor coinfected patients with the optimal attributes for good post-LT outcomes. To avoid excessive waiting times, patients should be encouraged to seek other sources of organs, such as live and domino donation, in an attempt to shorten waiting times. Where possible, the use of marginal (older, steatotic) grafts should be avoided in coinfected recipients, and the use of HCV-positive grafts should be cautious until more is known about the outcomes of LT using these organs. The major problem post-LT is HCV recurrence, which is the most common cause of graft loss. HCV recurrence is associated with steroid boluses to treat rejection episodes, and it is disappointing that rejection appears to be more frequent in coinfected recipients. Addressing the issue of rejection will decrease HCV recurrence and improve outcomes. This goal is achievable as we understand more about the interactions between calcineurin inhibitors and cART and become more adept at individualized immunosuppression protocols. Newer antiviral regimens without the use of protease inhibitors should facilitate the easier dosing of immunosuppression and lead to less rejection. The complexities of immunosuppression dosing and cART management highlight the importance of an experienced multidisciplinary team in the management of these patients. Such teams will only exist in larger centers, and given the association of center volume with mortality, it is arguable that this activity should only occur in centers transplanting regularly for this indication.

The new era of DAAs offers encouragement for the future in terms of treating patients both before and after transplantation. At the present time, the currently available protease inhibitors (telaprevir and boceprevir) are only active against genotype 1 infection, and drug interactions with cART and CNIs will limit their applicability in the post-transplant setting. Other DAAs will shortly be available, and case reports of successful treatment of post-LT HCV recurrence with drugs such as daclatasvir and sofosbuvir – albeit in a non-HIV setting – show promise for the future.[47,48]

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