icon-folder.gif   Conference Reports for NATAP  
  AASLD (American Association for the Study of Liver Diseases)
Nov 2-5, 2002, Boston, MA
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Liver Transplantation in HIV and HCV Coinfected Patients
Reported by Jules Levin
  French researchers (abstract 259; Didier Samuel et al) from the Hospital Paul Brosse in Villejuif, France reported on the results so far seen in 7 patients with HCV/HIV coinfection who received liver transplants. Average age of the patients was 40 and they underwent transplant between December 1999 and March 2002. All patients (6 men) had Child C cirrhosis, controlled HIV replication, average CD4 count of 275, no prior opportunistic infections. For immunosuppression to perform transplant Tacrolimus and steroids were used.
RESULTS. 3 patients received a domino graft (from a donor transplanted for familial amyloidotic polyneuropathy); 2 a living related donor graft and 2 a cdaver graft. 5 of the 7 are alive, and as the presenter said 4 are "alive and well", but post transplant experience can have complications which are described below. The average followup time for these patients is 12.8 months (4-30 months). The longest a patient is alive who is doing well is 30 months. In general transplant experience is that patients with hepatitis B have better outcomes than patients with hepatitis C. 3 patients are doing relatively well. The study presenter said 4 of the 7 patients have shown dramatic improvement. 1 patient is in good condition at month 30 and is HCV negative. a second patient has F1 fibrosis at month 12 of followup with low or undetectable HIV RNA and in good condition. A third patient is in good condition at month 18 of followup. Three patients are not doing well. Another patient is alive with F3 fibrosis at month 14. Two patients died. One patient died at month 22. And a second patient died at month 4 after developing severe liver disease.
Although I thought presenter said there have been no opportunistic infections in talk program abstract reports 1 patient had oesophageal candidosis. Patients have been able to achieve adequate control of HIV after transplant. 5 patients had undetectable HIV viral load, transiently positive in one and high in one after discontinuation of HAART.
Protease inhibitors and tacrolimus interaction was responsible for acute rejection by low tacrolimus level in 1 and for toxic levels of tacrolimus in 1.
HCV recurrence occurred in all patients with a 1-2 log increase in HCV viral load within the first 3 months post transplant. HCV acute hepatitis was seen in all 7 patients. One patient developed a severe chronic hepatitis C requiring combination therapy of interferon and ribavirin, which led to complete antiviral response. 4 patients developed mixed lesions of microvesicular steatosis, and of hepatitis C. One patient died of multiple organ failure due to HAART toxicity and of hepatitis C at 4 months. Still, study authors reported a significant improvement of quality of life and gain of weight in 5 of 7 patients. The authors concluded (1) HAART toxicity and HCV recurrence are the 2 main complications in this preliminary experience; (2) Liver transplantation in HCV/HIV coinfection is feasible but requires a cautious monitoring of HCV reinfection, of drug interactions and of antiretroviral toxicity.
During the question and answer period following the presentation someone from Kings College in London talked about their negative experience with transplanation for HCV/HIV coinfected and expressed doubts about the feasibility, but at the same time sites including the University of Pittsburgh, U of Miami, and Michelle Roland at UCSF have reported from preliminary results that HCV/HIV coinfected appear to have comparable outcomes from transplantation as patients with only HCV. As I said above, transplants in patients with HBV appear to have better outcomes than patients with HCV.