www.hivandhepatitis.com

AASLD 2009: Study Looks at Factors Affecting Survival of HIV/HCV Coinfected Liver Transplant Recipients

While HIV/HCV coinfected patients can have good outcomes after liver transplantation, acute organ rejection remains a risk factor and survival does not match that of HIV negative people with hepatitis C virus (HCV) alone, according to a study presented at the 60th Annual Meeting of the American Association for the Study of Liver Diseases (AASLD 2009) this month in Boston.

Norah Terrault and colleagues from transplant centers across the U.S. compared 1 and 3 year post-transplant survival and rates of severe hepatitis C recurrence in HIV/HCV coinfected versus HCV monoinfected liver transplant recipients, and identified predictors of these outcomes.

Hepatitis C is the most common indication for liver transplantation among people with HIV, the investigators noted as background. Prior studies suggest HIV positive individuals have a higher rate of mortality while on the donor liver waiting list and worse post-transplant survival, but data from the U.S. are limited.

The present analysis included all 81 HIV/HCV coinfected liver transplant recipients in the multicenter HIVTR (Solid Organ Transplantation in HIV) study cohort. For each case patient, the researchers selected 1-3 HCV monoinfected control subjects (total 213) matched for type of transplant (single or dual organ), presence or absence of hepatocellular carcinoma, and study site. MELD scores were similar in the 2 groups and similar proportions received liver grafts from HCV-infected donors.

Participants were followed for a media of about 1.5 years. Study endpoints were patient and graft (new liver) survival as well as severe HCV-related disease (cholestatic hepatitis, bridging fibrosis or cirrhosis, or graft loss due to HCV).

Results

• HIV/HCV coinfected patients were younger on average (50 vs 54 years) and received livers from younger donors (37 vs 42 years).
• Coinfected individuals were about twice as likely to have treated acute rejection than HCV monoinfected patients (35% vs 18%; P = 0.001).
• Coinfected patients also had a significantly higher likelihood of receiving anti-HCV therapy than those with HCV alone (38% vs 16%; P < 0.0001).
• 1-year graft survival rates were 71% for HIV/HCV coinfected patients compared with 86% for HCV monoinfected patients.
• 3-year graft survival rates were 59% and 67%, respectively (P = 0.01).
• In a multivariate analysis, the following factors were significant predictors of graft survival:
• Body mass index (BMI) less than 21: hazard ratio (HR) 3.3 (P = 0.02).
• Treated acute rejection: HR 3.4 (P = 0.01);
• Receiving a liver from an HCV-infected donor: HR 3.4 (P = 0.01);
• Dual kidney-liver transplant: HR 4.4 (P = 0.01);
• Splenectomy (spleen removal) (HR 4.4; P = 0.07) and use of tacrolimus (Prograf) rather than cyclosporine as an initial immunosuppressive drug to prevent graft rejection (HR 2.5; P = 0.10) were of borderline statistical significance.
• The 1-year cumulative incidence of severe HCV-related liver disease was 18% among HIV/HCV coinfected recipients compared with 8% among HCV monoinfected patients (P = 0.19).
• The only significant predictor of severe HCV recurrence was treated acute rejection; HIV status positively but not significantly associated (HR 1.7; P = 0.16).

Based on these findings, the investigators concluded, "Patient and graft survival were lower in [HIV/HCV] coinfected liver transplant patients than HCV monoinfected patients, but the key predictor of graft loss and severe HCV disease was treated acute rejection."

They added that, "These results support liver transplant in coinfected patients, but highlight the need for better markers of immune activation-suppression in this population, and suggest that dual kidney-liver transplants, low BMI, and use of HCV positive donors may confer a higher risk of poor outcome."

University of California-San Francisco, San Francisco, CA; EMMES Corporation, Rockville, MD; Mt. Sinai School of Medicine, New York, NY; Cedars Sinai Medical Center, Los Angeles, CA; Beth Israel Deaconess Medical Center, Boston, MA; University of Pittsburgh, Pittsburgh, PA; Rush University, Chicago, IL; Columbia University, New York, NY; University of Miami, Miami, FL; Georgetown Medical Center, San Diego, CA; University of Pennsylvania, Philadelphia, PA; Northwestern University, Chicago, IL; University of Cincinnati, Cincinnati, OH; Cleveland Clinic, Cleveland, OH; University of Chicago, Chicago, IL; Tulane University, New Orleans, LA; Johns Hopkins University, Baltimore, MD; University of Virginia, Charlottesville, VA.

11/13/09

Reference

N Terrault, B Barin, TD Schiano, and others. Survival and Risk of Severe Hepatitis C Virus (HCV) Recurrence in Liver Transplant (LT) Recipients Coinfected with Human Immunodeficiency Virus (HIV) and HCV. 60th Annual Meeting of the American Association for the Study of Liver Diseases (AASLD 2009). Boston. October 30-November 1, 2009. Abstract 195.