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HIV Coinfection Does Not Worsen Liver Transplant Outcomes in People with Hepatitis B or C

HIV positive liver transplant recipients with hepatitis B virus (HBV) or hepatitis C virus (HCV) coinfection did not fare worse overall than HIV negative people, according to a Spanish study presented at the 50th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2010) last month in Boston. Coinfected patients were less likely to experience organ rejection, but HCV recurrence was a leading cause of adverse outcomes.

About one-third of HIV positive individuals are estimated to be coinfected with hepatitis B or C. Coinfection has been linked to accelerated liver disease progression and poorer response to interferon-based hepatitis treatment.

Several studies conducted earlier in the HIV/AIDS epidemic showed that people with HIV had more complications and shorter survival after liver transplantation compared with their HIV negative counterparts, but much of this work was done before the development of optimally suppressive and well-tolerated combination antiretroviral therapy (ART). More recent comparisons have found that HIV positive and HIV negative patients can obtain similar outcomes.

In the present study, investigators from Hospital Ramon y Cajal in Madrid looked at complications and mortality among all 184 positive patients who received liver transplants at their center between January 2001 and May 2010 due to cirrhosis associated with viral hepatitis. Within this group, 18 people (10%) were HIV positive.

Results

• HIV positive transplant recipients were significantly younger on average than HIV negative patients (44 vs 52 years, respectively).
• In addition, HIV positive patients, relative to those without HIV, had the following attributes:
• Less likely to have hepatocellular carcinoma (HCC) as a transplant indication (33% vs 53%, respectively);
• Significantly less likely to have both HBV and HCV (27% vs 5%, respectively;
• Less likely to have HBV without HCV (0% vs 14.5%).
• MELD scores -- a measure of liver disease severity used to prioritize waiting-list patients -- were similar (17 vs 15 overall, or 19 in both groups if excluding those with HCC).
• No HIV positive recipients died within 90 days of transplantation, compared with 13% of HIV negative patients.
• HIV positive patients were also less likely to require a second transplant (0% vs 8%, respectively).
• HIV positive people were about one-third as likely to experience acute organ rejection after transplantation (11% vs 33%, respectively).
• The HIV positive group was considerably less likely to have cytomegalovirus (CMV) infection (44% vs 25%, respectively).
• None of these differences, however, reached statistical significance, perhaps due to the small number of people in the HIV positive group.
• In a multivariate analysis, independent predictors of mortality after liver transplantation included:
• Higher MELD score: hazard ratio (HR) 1.072;
• Older age at the time of transplantation: HR 1.047;
• CMV infection: HR 2.605.
• HIV positive and HIV negative patients had similar cumulative survival rates after transplantation:
• 1 year: 100% vs 86%, respectively;
• 3 years: 84% vs 76%, respectively;
• 5 years: 68% vs 65%, respectivey.
• After a median follow-up period of 126 weeks (range 1-462 weeks), survival rates differed according to transplant indication:
• HBV and HCV coinfection: 100% survival;
• HBV alone: 75% survival;
• HCV alone: 60% survival.
• Looking only at 160 patients with HCV, complications were somewhat more common among HIV positive compared with HIV negative individuals, but only mortality was statistically significant:
• Severe HCV recurrence (17% vs 11%);
• Use of pegylated interferon plus ribavirin (39% vs 36%);
• HCV-related death (100% vs 24%).

"In viral cirrhotic subjects undergoing liver transplantation, HIV coinfection did not worsen outcomes within the first 5 years, although 100% of deaths (n=3) were related to HCV recurrence," the researchers concluded. "HIV patients showed lower rates of rejection and higher rates of CMV infection after liver transplantation.

Investigator affiliation: Hospital Ramon y Cajal, Madrid, Spain.

10/8/10

Reference
A Moreno, S Del Campo, R Barcena, and others. In the HAART Era, in Patients with Viral Cirrhosis Undergoing Liver Transplantation, HIV-Coinfection Does not Lead to Five-Year Reduced Survival. 50th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2010). Boston, September 12-15, 2010. Abstract V-1792.Looking only at 160 patients with HCV, complications were somewhat more common among HIV positive compared with HIV negative individuals, but only mortality was statistically significant: