Liver transplant

In cases of severe cirrhosis or hepatocellular carcinoma, a liver transplant may be the only viable treatment option. There is currently a serious shortage of donated livers. Individuals who are psychologically unstable, who use illegal drugs or who consume large amounts of alcohol currently do not have access to transplants in the United Kingdom.

Recent studies have shown that transplant outcomes in selected HIV-positive people can be nearly as good as those seen in people without HIV.1,2,3 A United States team studying both liver and kidney transplants in HIV-positive individuals has reported encouraging results.4Transplants in HIV-positive and co-infected people are also under study in the United Kingdom and elsewhere in Europe.5,6,7

Transplant outcomes are most successful in people with well-controlled HIV disease. Post-transplant survival is poorer among HIV-positive individuals with CD4 cell counts below 200 cells/mm3 and those who are unable to tolerate HIV therapy.3 Some patients who formerly could not tolerate antiretroviral drugs can do so after they receive a new liver. Concerns that immunosuppressive drugs used to prevent organ rejection would worsen HIV disease progression have not been borne out, but such drugs must be used with caution due to interactions with antiretroviral medications.8 Survival rates will likely improve as doctors become more experienced in managing the complex immunological factors and drug interactions affecting HIV-positive transplant patients. However, HCV usually infects the new liver soon after a transplant.2,5

Following the success of transplants in this patient group, some experts have advocated for a routine approach to liver transplants in HIV-infected patients. In 2005, BHIVA and the United Kingdom and Ireland Liver Transplantation Centres issued guidelines recommending that HIV-positive patients with hepatitis B or C should be considered for liver transplants if they have at least a 50% chance of surviving five years or more after receiving a new liver. They also recommend that patients have CD4 cell counts above 200 cells/mm3 (or 100 cells/mm3 with portal hypertension), undetectable HIV viral loads, no AIDS-defining illnesses and antiretroviral drug options available. Contraindications include alcohol-related liver disease, unless abstinent for over six months, intravenous drug use and other cancers or circulatory disorders.9

References

  1. de Vera ME et al. Progression and treatment of recurrent hepatitis after liver transplantation in patients co-infected with HIV. Hepatology 38: S161A, 2003
  2. Neff GW et al. Update on orthotopic liver transplantation in human immunodeficiency syndrome (HIV) + patients with coinfection. 42nd Interscience Conference on Antimicrobial Agents and Chemotherapy, San Diego, abstract H-1741, 2002
  3. Ragni MV et al. Survival of human immunodeficiency virus-infected liver transplant recipients. J Infect Dis 188: 1412-1420, 2003
  4. Roland M et al. 1- to 3-year outcomes in HIV-infected liver and kidney transplant recipients. Twelfth Conference on Retroviruses and Opportunistic Infections, Boston, abstract 953, 2005
  5. Norris et al. Outcomes of liver transplantation in HIV-infected individuals: the impact of HCV and HBV infection. Liver Transpl 10: 1271-1278, 2004
  6. Rufi G et al. Orthotopic liver transplantation in 15 HIV-1-infected recipients: evaluation of Spanish experience in the HAART era (2002-2003). Eleventh Conference on Retroviruses and Opportunistic Infections, San Francisco, abstract 827, 2004
  7. Vogel M et al. Orthotopic liver transplantation in HIV-positive patients: outcome of 10 patients from the Bonn Cohort. Twelfth Conference on Retroviruses and Opportunistic Infections, Boston, abstract 931, 2005
  8. Teicher E et al. Liver transplantation in HIV-HCV co-infected patients. Eleventh Conference on Retroviruses and Opportunistic Infections, San Francisco, abstract 828, 2004
  9. O'Grady J et al. Guidelines for liver transplantation in patients with HIV infection. HIV Med 6: S149-S153, 2005
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