Prior studies indicate that HIV
positive individuals tend to experience more rapid liver disease progression
than HIV negative individuals. Research shows that people with well-controlled
HIV disease can achieve liver transplant outcomes nearly as good as those of HIV
negative patients.
The
model for
end stage liver disease (MELD) score - derived from serum bilirubin and creatinine
levels and INR (international normalized ratio, a measure of blood clotting) --
is accepted as a reliable predictor of mortality among HIV negative transplant
candidates, but factors that predict death have not been established in HIV positive
candidates. A MELD score of 25 or greater is typically used as an indication for
transplantation.
A total of 167 HIV-infected
participants enrolled in the Solid Organ Multi-Site Transplant Study (HIVTR) were
matched with up to 5 HIV negative control subjects from the United Network of
Organ Sharing (UNOS) with regard to age, sex, race, time period, and hepatitis
C virus (HCV) status. About 75% of the HIV positive patients were coinfected
with HCV. Overall, the HIVTR participants had well-controlled HIV and most
were on HAART.
Results
•
Of 167 HIVTR participants, 58 (35%) received
transplants, 24 (14%) died prior to transplantation, and 85 (51%) survived without
a transplant.
•
The pre-transplant mortality rate of 14% was
similar to that of UNOS control subjects, at 11% (88 of 792).
•
There was no difference in pre-transplant
mortality between HIV-HCV coinfected participants (14%) and HCV monoinfected UNOS
controls (11%).
•
Cumulative incidence of death, transplantation,
and elevation of MELD score ? 25 were similar for HIVTR participants and UNOS
control subjects.
•
In both groups, baseline MELD (both ? 25 and
? 20) was a significant predictor of pre-transplant mortality.
•
Sepsis (bloodstream infection) and multiple
organ system failure were the main causes of death.
•
In the HIVTR group, those who died had a significantly
lower median CD4 cell count at enrollment (237 cells/mm3) than those who received
transplants (315 cells/mm3) or survived without transplantation (264 cells/mm3).
•
The proportion of patients with detectable
HIV RNA (> 400 cells/mm3) did not differ between those who died (21%), those
who received transplants (16%), and those who survived without transplants (7%).
•
However, detectable HIV RNA was associated
with an increased risk of death and faster progression to MELD score ? 25.
•
HCV status was similar in patients who died,
received transplants, or survived without transplants.
•
In a multivariate analysis, the only significant
predictor of mortality was having a baseline MELD score ? 25 (HR 21.8; P <
0.0001).
Conclusion
"HIV
positive liver transplant candidates have similar pre-transplant mortality characteristics
as HIV negative controls," the researchers concluded. "While lower CD4
counts and detectable HIV RNA are associated with death, baseline MELD appears
to be the only significant predictor of pre-transplant mortality in HIV-infected
liver transplant candidates."
They
recommended that, "HIV providers should routinely calculate MELD scores in
their patients with cirrhosis to help guide decisions on referral for transplant
evaluation."
In
discussing the study results, presenter Aruna Subramanian acknowledged that the
influence of elevated bilirubin level on MELD score would have to be taken into
account for patients receiving atazanavir
(Reyataz).
She
said that data on post-transplant outcomes are currently being collected, but
preliminary findings appear to suggest that HIV-HCV coinfected patients may have
worse outcomes than those without HCV.
Johns
Hopkins Univ, Baltimore, MD; EMMES Corp, Rockville, MD; Beth Israel Deaconess
Med Ctr, Boston, MA; Cedars-Sinai Med Ctr, Los Angeles, CA; Columbia Univ, New
York, NY; California Dept of Publ Hlth, Sacramento, CA; Univ of California, San
Francisco, CA; Univ of Pittsburgh, PA.
2/19/08
Reference A
Subramanian, M Sulkowski, B Barin, and others. MELD is the Best Predictor of Pre-transplant
Mortality in HIV-infected Liver Transplant Candidates. 15th Conference on Retroviruses
and Opportunistic Infections (CROI 2008). Boston, MA. February 3-6, 2008. Abstract
64.
MELD
Score Is the Best Predictor of Outcomes among HIV Positive Liver Transplant Recipients
Results
