HIV-positive patients who have a liver transplant because of
liver cancer can have good outcomes, French research published in the February
edition of Hepatology shows.
The study compared rates of overall survival and recurrence-free
survival between HIV-positive and HIV-negative patients who were candidates for
a transplant because of liver cancer. Because of higher dropout rates when on
the waiting list, outcomes were poorer for those with HIV. However, for those
who had a transplant, survival rates were comparable for HIV-positive and
Large numbers of HIV-positive patients are co-infected with
hepatitis B or hepatitis C. Liver disease caused by these viruses is now the
most important cause of death in co-infected patients, and a large proportion
of this mortality is due to hepatocellular carcinoma, or liver cancer.
A number of studies have shown that HIV-positive patients are
often good candidates for liver transplant, but information on the outcome of patients
who have had a transplant because of liver cancer is limited.
Therefore Dr René Adam and his colleagues from the
Hospital Paul Brousse performed a study analysing overall survival and disease
free survival for HIV-positive and HIV-negative individuals who had a
transplant because of liver cancer. Patients who received care between 2003 and
2008 were included in the investigators’ analysis.
All the HIV-positive patients were taking successful
antiretroviral therapy and none had an AIDS-defining illness.
A total of 21 HIV-positive and 65 HIV-negative individuals
were included in the study. The two patient groups had similar characteristics,
although those with HIV had a younger median age (48 vs. 57 years, p <
Patients with HIV were more likely to dropout of care when
on the waiting list than those who HIV-negative (23% vs. 10%).
Higher alphafetoprotein (AFP) levels were associated with an
increased risk of drop-out among patients with HIV (p = 0.03). An increase in
AFD level of above 15 µg/l per month was also predictive of dropout for HIV-positive
individuals (p = 0.02). Only one HIV-positive patient dropped out because he
developed an AIDS-defining illness.
A total of 16 HIV-positive and 58 HIV-negative individuals
underwent a transplant.
Overall, three patients died within two months of their
transplant. One patient was HIV-positive and the cause of death was rupture of
the hepatic artery.
Analysis that included all patients who were put on the list
for transplant showed that survival rates were poorer for those with HIV. One
and three-year survival rates were 81% and 55% for HIV-positive patients
compared with 91% and 82% for HIV-negative individuals (p = 0.005).
However, survival did not significantly differ by HIV status
for individuals who had a transplant.
Overall one and three year overall survival rates for
patients with HIV were 81% and 74% versus 93% and 85% for HIV-negative
individual. These differences were not significant
After transplant, liver cancer recurred in 31% of
HIV-positive and 15% of HIV-negative patients. The median time to the
reappearance of cancer was eleven and 18 months respectively, and 80% of
HIV-positive and 33% of HIV-negative individuals died. More advanced liver
cancer and AFP progression when on the waiting list were both associated with
the recurrence of cancer.
The one and three-year recurrence-free survival rates after
transplant for HIV-positive patients were 69% and 69%, compared to 89% and 84%
for those who were HIV-negative. These differences were not significant.
“The negative impact of HIV infection on overall survival
after listing was the result of a higher drop-out rate and death occurring
rapidly after recurrence,” comment the investigators, who add, “HIV-positive
patients died almost twice as quickly as HIV-negative patients after a
recurrence (12 versus 21 months).”
They believe their findings “emphasizes the importance of
monitoring AFP levels during the waiting period in order to detect HIV-positive
patients with a high risk of dropout or early recurrence after liver
Nevertheless, the investigators’ conclusion is optimistic,
and they write: “If HIV-positive patients are selected for liver transplant on
the basis of strict criteria and are kept under close surveillance until
surgery, there are no objective arguments to contraindicate liver transplant in
this young patient population.”