HIV status does not affect liver transplant outcomes, 15-year Spanish study finds

People with HIV who received liver transplants in Spain were just as likely to survive and not experience organ rejection as people without HIV during a 15-year follow-up period, an analysis of liver transplant recipients treated at the University of Barcelona’s Hospital Clinic has found.

The findings were presented on Wednesday at the HIV Drug Therapy Glasgow 2024 conference. Liver transplantation is necessary in end-stage liver disease and in some cases of hepatocellular carcinoma. Higher rates of end-stage liver disease and liver cancer caused by hepatitis C are seen in people with HIV compared to the rest of the population. People with HIV and hepatitis C coinfection have been receiving liver transplants since studies conducted in 2000 demonstrated short-term safety and efficacy of the procedure.

But although studies have reported short-term outcomes, it has been unclear if people with HIV who receive liver transplants have the same long-term outcomes as people without HIV.

To address this question, Professor Jose Miro and colleagues at the University of Barcelona Hospital Clinic carried out a retrospective case-control in which they matched people with HIV who received liver transplants between 2003 and 2012 and matched each patient with three HIV-negative liver transplant recipients treated at the same hospital. Recipients were matched by year of transplant, age, gender, hepatitis B or C coinfection and the presence of hepatocellular carcinoma.

The study matched 24 people with HIV with 72 HIV-negative controls. Study participants had a median age of 49 years at the time of transplant and 67% were male. All participants had viral hepatitis: 92.7% had hepatitis C alone, 4.2% had hepatitis B alone and 3.1% had both hepatitis B and C. Whereas 84% of people without HIV had hepatitis C genotype 1, the range of hepatitis C genotypes was more varied in people with HIV (genotype 1 – 42%, 3 – 25%, 4 – 21%, other – 13%).

Eighty-five percent of transplant recipients had detectable hepatitis C virus at the time of transplant and 28% had hepatocellular carcinoma. After a median follow-up period of 12.7 years (interquartile range 5.5 – 15.2 years), just over one in three (36%) of transplant recipients had died, 4% had undergone another transplant and subsequently died, 3% underwent another liver transplant and were alive, 51% were alive and 5% were lost to follow-up. There was no statistically significant difference in outcomes between people with and without HIV.

The most common cause of death in both groups was liver disease (19 out of 35 deaths), predominantly caused by relapse of hepatitis C (13 deaths). The majority of deaths (28) occurred before the introduction of direct-acting antivirals for hepatitis C treatment in 2015. But everyone who survived and had hepatitis C at the time of transplantation achieved eradication of hepatitis C through direct-acting antiviral treatment.

Overall, there was no statistically significant difference between people with and without HIV in causes of death. The prevalence of most comorbidities was similar in people with and without HIV, with the exception of a higher prevalence of chronic kidney disease in people with HIV (62% vs 28%, p=0.047) and a higher prevalence of type 2 diabetes in people without HIV (53% vs 7%, p=0.001). The prevalence of cardiovascular disease was high in both groups (71% in people with HIV and 75% in people without HIV).

Almost all people with HIV who survived after transplantation had suppressed viral load at all follow-up visits, with the exception of one person who had erratic medical follow-up. Median CD4 counts improved from 189 cells/mm³ one month after transplantation to 331 one year after transplantation. The CD4/CD8 ratio (a marker of vulnerability to infections and non-AIDS-defining serious conditions) improved from 0.5 after transplantation (abnormal) to 0.72 (approaching normal) 15 years after transplantation.

The researchers say that the findings, the first European study on long-term outcomes after liver transplantation in people with HIV, support the use of liver transplants for people with HIV wherever they are clinically indicated.

The same research group carried out a survey to assess the willingness of clinicians at 37 hospitals in Spain to transplant kidneys from HIV-positive donors to people with HIV in need of an organ. The procedure is permitted in several European countries, the United States and South Africa, but not in Spain.

Two-thirds of specialists working in transplant teams (99 people) responded. Respondents were asked to indicate how strongly they agreed with permitting the use of kidneys from donors with HIV of various types, ranging from deceased donors who were virally suppressed to virally unsuppressed donors not on antiretroviral treatment.

Respondents agreed strongly that virally suppressed donors, living or deceased, were suitable but rejected the idea that organs from people with unsuppressed HIV could be given to other people with HIV.

Transplant co-ordinators responding to the survey estimated that 94 organs from virally suppressed people with HIV had been barred from potential transplantation in the last 20 years, 36 of these in the period 2015-2019.

The researchers hope that their findings will persuade the Spanish government to change the law to permit kidney transplants from donors with HIV, enabling more people with HIV to benefit from a kidney transplant.

This article was first published on the website of HIV Glasgow. At the time of the conference, aidsmap had temporarily suspended operations, but the conference organisers commissioned a group of aidsmap writers to report from the meeting. Following the relaunch of aidsmap, we are pleased to republish the article here.