By Liz Highleyman

Until a few years ago, HIV positive individuals were typically considered ineligible for organ transplants due to a high risk of poor outcomes. This changed, however, with the advent of combination antiretroviral therapy that enabled full HIV suppression, good immune recovery, and longer life expectancy.

At the 43rd annual meeting of the European Association for the Study of the Liver (EASL) last week in Milan, researchers presented data on outcomes of liver transplantation among HIV positive individuals in Italy, most of whom were coinfection with hepatitis C virus (HCV) or hepatitis B virus (HBV).

To evaluate possible extension of the indication for orthotopic liver transplantation to include HIV-infected individuals, the Italian National Centre for Transplantation nominated a committee of experts to design a protocol to be applied on a national basis. This pilot program specified strict inclusion criteria for liver transplant recipients, namely having a CD4 count > 200 cells/mm3 and undetectable HIV viral load for at least 3 months for patients on antiretroviral therapy. For patients with a previously documented response to HAART, but who are unable to tolerate HAART due to decompensated liver disease, the CD4 count must be > 100 cells/mm3.

The program was voluntarily adopted by 6 Italian liver transplant centers. Between September 2002 and November 2007, 60 HIV positive individuals with liver cirrhosis underwent transplantation using cadaver donors. Most (53) were men, with a mean age of 43 years (range 34-58).

Results

• The median waiting time for a liver transplant was 74 days (range 2-850 days).

• Liver transplantation was secondary to:

• hepatitis C virus (HCV): 39 patients;

• hepatitis B virus (HBV): 5 patients;

• both HCV and HBV: 5 patients;

• HBV and hepatitis delta virus (HDV): 2 patients;

• HBV, HBV, and HDV: 5 patients;

• cryptogenic (cause unknown) hepatocellular carcinoma (HCC): 1 patient;

• Rendu-Osler syndrome: 1 patient;

• data unavailable: 2 patients.

• 23 patients (39.7%) had concurrent HCC.

• The median CD4 cell count at the time of transplantation was 354 cells/mm3 (range 119-977 cells/mm3).

• HIV RNA was undetectable in 86.4% of the transplant recipients.

• Overall survival was 58.3% (41 out of 60 patients) after a median follow-up of 350 days after transplantation (range 4-1720 days).

• All HCV-infected recipients experienced recurrent HCV infection of the donor liver after transplantation.

Conclusion

Based on these findings, the investigators concluded that, "The short term results of [orthotopic liver transplant] in HIV-infected individuals are slightly inferior when compared with those observed in HCV or HBV monoinfected [orthotopic liver transplant] recipients."

University of Insubria, Varese; National Centre of Transplantation, Rome.

4/29/08

Reference
PA Grossi, F Gabbrielli, C De Cillia, and others. The Italian Experience of Liver Transplantation in HIV-Infected Individuals. 43rd annual meeting of the European Association for the Study of the Liver (EASL 2008). Milan, Italy. April 23-27, 2008.