Long-term Outcomes After Liver Transplantation Among Human Immunodeficiency Virus–Infected Recipients

Abstract

Background Early outcomes after HIV+ liver transplantation (LT) are encouraging, but data are lacking regarding long-term outcomes and comparisons with matched HIV− patients. Methods We examined outcomes among 180 HIV+ LT, and compared outcomes to matched HIV− counterfactuals (SRTR 2002–2011). Iterative expanding radius matching (1:10) on recipient age, race, BMI, hepatitis C infection (HCV), MELD score, and acute rejection; and donor age and race, CIT, and year of transplant. Patient survival and graft survival were estimated using Kaplan-Meier methodology and compared using log-rank and Cox proportional hazards. Subgroup analyses were performed by transplant era (early: 2002–2007 vs. modern: 2008–2011) and HCV-infection status. Results Compared to matched HIV− controls, HIV+ LT recipients had a 1.68-fold increased risk for death (aHR: 1.68, 95% CI: 1.28–2.20, p<0.001), and a 1.70-fold increased risk for graft loss (aHR: 1.70, 95% CI: 1.31–2.20, p<0.001). These differences persisted independent of HCV-infection status. However, in the modern transplant era risk for death [aHR: 1.11; 95% CI: 0.52–2.35, p=0.79] and graft loss [aHR: 0.89; 95% CI: 0.42–1.88, p=0.77] were similar between monoinfected and uninfected LT recipients. In contrast, independent of transplant era, coinfected LT recipients had increased risk for death [aHR: 2.24; 95% CI: 1.43–3.53, p < 0.001] and graft loss [aHR: 2.07, 95% CI: 1.33–3.22, p=0.001] compared to HCV+ alone LT recipients. Conclusion These results suggest that outcomes among monoinfected HIV+ LT recipients have improved over time. However, outcomes among HIV+ LT recipients coinfected with HCV remain concerning, and motivate future survival benefit studies.

Key donor factors associated with graft loss among liver transplant recipients with human immunodeficiency virus

“…For patients infected with human immunodeficiency virus (HIV) who have complications of cirrhosis including small hepatocellular carcinoma (HCC), liver transplantation (LT) can be the only life‐saving treatment option . Overall survival rates are comparable to those achieved with older LT recipients without HIV infection, with 1‐ and 3‐year liver graft survival rates of 82% and 64%, respectively . However, the 3‐ and 5‐year patient survival rates of 62% and 54% are lower among HIV–HCV‐coinfected LT recipients compared to their HCV‐positive, HIV‐uninfected counterparts …”

“…1 Overall survival rates are comparable to those achieved with older LT recipients without HIV infection, with 1-and 3-year liver graft survival rates of 82% and 64%, respectively. 2,3 However, the 3-and 5-year patient survival rates of 62% and 54% are lower among HIV-HCV-coinfected LT recipients compared to their HCV-positive, HIV-uninfected counterparts. [4][5][6] Identifying means of improving outcomes is of critical importance.…”

Transplant Infectious Diseases: A Review of the Scientific Registry of Transplant Recipients Published Data

“…This hypothesis is supported by the gradual decline in anti-HBc + deceased kidney donors as well This practice is well accepted as the waiting time for a kidney from an HCV + donor is considerably shorter than that for a kidney from an HCV antibody negative (HCV -) donor (15). It is also possible that that the HCV + donors were HCV NAT negative and the recipient transplant center was aware of this information when the (18)(19)(20) and queries of SRTR data (21)(22)(23), and these trends are likely to either remain stable or increase in the future. Because HCV transmission has been rarely reported (16,17) in the era of nucleic acid testing (NAT), this may be due to error in data entry.…”

Human Immunodeficiency Virus

“…HUMAN IMMUNODEFICIENCY VIRUS 55 extensively studied. Experience from the Multicenter NIH HIV Organ Transplantation trial and many other centers now shows that overall outcomes are acceptable and improving with time, and in many cases now approximate outcomes similar to those seen in their HIV-negative counterparts (10)(11)(12). The subset of patients with hepatitis C virus and HIV coinfection, however, have significantly worse outcomes after kidney or liver transplantation as compared to their hepatitis C virus or HIV monoinfected counterparts, raising concerns about transplantation in this group.…”

“…These data predate the current hepatitis C virus treatment era that will likely have an additional profound impact on outcomes and deserves further study. Of note, while HIV progression was not seen in patients undergoing transplant as measured by increased opportunistic infections compared to HIV-negative transplant recipients, increased organ rejection events have been described (10)(11)(12). Furthermore, appropriate dosing of immunosuppressive agents has been very challenging based on drug-drug interactions with commonly used ARVs, particularly ritonavir-or cobicistat-boosted protease inhibitors; newer agents may alleviate some of those challenges.…”