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Liver Transplantation in HIV Infected Patients
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Jose Miro delivered a very nice overview of liver transplantation in coinfection on the last day of the Workshop.
TOPICS FOR THIS TALK
1. Prognosis of End Stage Liver Disease (ESLD)
2. Mortality on liver transplant waiting list
3. Current HIV inclusion criteria for OLT
4. Current Liver Transplant experience in US and Europe
5. Treatment of HCV re-infection
6. Conclusions & Future research areas
1. Prognosis of End-Stage Liver Disease
The Average Number of Years for Cirrhosis To Develop is15 Years in Coinfected Patients Compared to 30 years in HCV Monoinfected Patients.
55% of HIV-Infected in Spain have HCV and 5% have HBV. Of the 8% with liver cirrhosis, 27% with liver cirrhosis have Child-Pugh B stage, and 7% have Child-Pugh C stage, and 17% of these patients are Liver Transplant candidates.
Approximately 500,000 HIV-infected in North America have HCV or HBV. Of these 33,000 have liver cirrhosis, and of these about 15% are liver transplant candidates. Miro reports there are 5,700 liver transplant candidates in North America and 3,060 in Western Europe.
Complications of cirrhosis in HIV and non-HIV-infected patients
- Ascites
- Gastroesophageal variceal bleeding
- Non-obstructive jaundice
- Spontaneous bacterial peritonitis (SBP)
- Hepatic encephalopathy (HE)
- Hepatorenal syndrome (HRS)
- Hepatocellular carcinoma (HCC)
Cardenas & Gines, J Hepatol, 2005; Bruix, J Hepatol, 2001
Median Survival for coinfected patients in this study with cirrhosis after the first hepatic decompensation event was 14 months (3-42). (cause of death: ESLD).
2. Mortality on OLT Waiting List
HIV+ Patients on Liver Transplant Waiting List Die More Quickly Compared to HIV-negative Patients.
Survival While Waiting on waiting List for Transplant is Shorter for HIV+ Compared to HIV-
Spanish Cohort of HIV+ Patients with Orthotopic Liver Transplantation (OLT): Evaluation of 50 Cases in HAART Era (2002-05)
Jose Miro provided a preview of his presentation at CROI 2006 on liver transplantation in HIV+ individuals in Spain. There have been 50 OLTs from Jan 2002 through Oct 2005 in HIV+ patients.
The cause of liver cirrhosis was: HCV 42 patients (84%); 2 due to HBV (4%); and 6 with HBV+HCV (12%). 7 patients (14%) had HCC; 4 patients had alcohol use and 1 case porphyria; HCV genotypes 1, 2, 3, and 4 were detected in 25 (57%), 2 (4%), 8 (18%) and 6 (14%) cases respectively. Three cases had a non-typable genotype; 3 cases of Delta coinfection.
3 patients had Child-Pugh stage A (6%); 25 patients had B (50%); and 22 cases (44%) had C.
The median MELD was 15 (11-17).
80% were men. Average age was 40 (38-45). 72% were IVDUs, 12% sexual risk factor (heterosexuals, 3 homosexuals), 8% hemophilia, and 8% other.
Before transplantation the ART regimens patients were taking were: EFV HAART 24 (48%), PI-based HAART 12 (24%), 3-4 NRTI-based abacavir based regimen 8 (16%), other combinations 6 (12%). Average CD4 count was 275 (192-369); 44 (88%) patients had <200 copies/ml viral load.
Average time on waiting list was 3 months (2-7). Type of liver: cadaveric 96%; living-donor 4%. Moratlity: 10 died (20%). Followup is an average of 12 months (5-24), 2 patients required retransplantation.
MORTALITY
Early mortality (<3 mos), 4 (40%): 3 post-op. complications; 1 massivevariceal bleeding.
Late mortality (>9 mos) 6 (60%): 5 graft ELSD- HCV reinfection; 1 chronic reinfection.
Kaplan-Meier estimates of Survival:
85% (70-93%) at 1 year
75% (56-86%) at 2 years
66% (42-82%) at 3 year.
Comparing HIV- & HIV+ there was no statistical difference.
Post-Op Complications (n=50)
Hospitalization stay: 19 days (14-29)
Surgical Complications
- Biliary fistula 3 (8%)
- Peritoncal hemorrhafe 3 (8%)
- steatosis of hepatic artery 2 (6%)
other complications 2 (6%)
Immunosuppressive Regimens
Cyclosporine A (CsA)
Prednisone, or 7 (14%) IL-2
5. Treatment of HCV Reinfection
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