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 HIV-negative patients.
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 < 0.001).
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 transplant.”
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.”
Vibert E et al. Liver transplantation for hepatocellular carcinoma: the impact of human immunodeficiency virus infection. Hepatology, 475-82, 2011 (click here for the free abstract).