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Long-Term Outcomes of Liver Transplant Recipients Living With HIV: A Multicenter Case-Control Study
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Daniela Malano-Barletta1, Lucia Serrano2, Sheila Blanco1, Santos Del Campo3, Lluis Castells4, Jesus Fortun5, Laura Llado6, Pablo Ruiz1, Jordi Navarro Mercade1, Nuria Sabe6, Montse Laguno1, Gloria de la Rosa1, Asuncion Moreno1, Antoni Rimola1, Jos. M. Mir.1, for the FIPSE LT-HIV Investigators
1Hospital Clinic of Barcelona, Barcelona, Spain, 2Hospital La Paz Institute for Health
Research, Madrid, Spain, 3Ramon y Cajal Hospital, Madrid, Spain, 4Hospital Universitari Vall d'Hebron, Barcelona, Spain, 5University Hospital Ramon y Cajal, Madrid, Spain, 6Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
Background: Solid organ transplantation (SOT) in patients living with HIV (PWH) has become more widely adopted. However, data on long-term patient and graft survival are very limited, and studies analyzing the comorbidities that these patients develop over time are lacking. We aimed to compare 15-year liver transplantation (LT) outcomes between HIV+/HIV- recipients and to evaluate comorbidity prevalence in survivors.
End-stage liver disease (ESLD) and hepatocellular carcinoma (HCC) has been common in PWH co-infected with HCV and/or HBV, frequently requiring LT.
We aimed to compare 15-year LT outcomes between HIV+/HIV- recipients and to evaluate comorbidity prevalence.
Methods: This multicenter, retrospective, case-control study included 340 patients (85 HIV+ and 255 matched HIV- controls) transplanted between 2003–2012 in four Spanish centers and followed to July 2025. HIV+ recipients were matched with HIV- recipients (1:3 ratio) by center, calendar year (Å}1 yr), age (Å}12 yrs), gender, HCV/HBV co-infection, and hepatocellular carcinoma (HCC). A descriptive analysis was performed. Survival time from LT was estimated using the Kaplan-Meier product-limit method; the curves obtained in HIV+ and HIV- recipients were compared using the generalized log-rank test (univariate Cox model analysis).
Patients were followed until death, graft failure requiring retransplant and last control alive.
Comorbidities were classified using ICD-10 (International Classification of Diseases) codes.
Predictors of death and graft failure were determined performing a Cox proportional hazards analysis.
SPSS 28.0 software (IBM Corp) was used for the analyses.
Results: Overall, 82% of cases were males; median (IQR) age was 48 (44–53) years; among PWH, 72% were former drug addicts; and globally 88% of the patients had an active HCV infection at the time of LT. GT1 44% in HUV, 74% in HIV-neg. GT4 21% in HV+, 4.4% in HIV-neg., GT3, 22% in HIV+, 12% in HIV-neg.
After a median (IQR) follow-up of 12 (3-16) years, 172 patients (50%) remained alive with no differences between HIV+ and HIV- groups (52%% HIV-neg. vs 45% HIV+ p= 0.329). HIV+ patient and graft survival rates (95% Confidence Interval) at 15 years were 50% in HIV+ and 47%% in HIV-neg., respectively, compared to 47% and 43%for HIV- recipients (Figure 1A/1B).
Overall, main cause of death was HCV recurrence/relpase (11.8% recurrence, 30% relapse, liver disease non HCC/HCV related 4.7% in HIV+, 12.6% in HIV-neg p-value 0.170; CVD 4.7% HIV, 10.5% HIV-neg.), Non-AIDS-related cancer 15%, mostly before the era of anti-HCV direct acting antivirals. HCV was eradicated in all survivors.
The development of comorbidities (HIV+/HIV-) (gastrointestinal [21%, 21%], cardiovascular [55%, 64%], neurological [28%, 21%], bone [26%, 17%, renal [50%, 48%; dialysis; 10%, 6.75], respiratory [18%], metabolic [58%, 65%], and infectious diseases) and de novo cancer was similar in both groups, except for diabetes mellitus which was more frequent in HIV recipients (24% vs. 43%, p=0.005).
Comorbidities, ADE, & Non-ADEs
AIDS & Non-AIDS related infections: 46%, 41%
AIDS related infections 21% in HIV+
Non-AIDS defining cancer 31%, 38%
HCC Recurrence/HCC do novo: 6 (7.8% / 0/0); 21 (9.7% / 2 (0.9%).
AIDS defining cancer: 3 (4.1%): 2 non-Hodgkin lymphomas & 1 cervical carcinoma
hypertension: 55%, 64%
Ischemic heart disease (medically treated) 13%, 8% ( anger pectoris, acute MI, revascularization)
Stroke: 6.8%, 8.5%.
MACE 18.9%, 13.3% (acute MI and/or stroke)
Heart failure: 6.8%, 8.5%.
Peripheral vascular disease: 5.4%, 2.8%
others: 13.5%, 11.3%
At last visit, all PWH were suppressed on ART and median (IQR) CD4+ T-cell count was 330 (233-509) cells/μL. Integrase strand-transfer inhibitors-based ART was the most common regimen (76%) in recent years, as dual (14%) or triple (62%) therapy.
Conclusions: This multicenter study showed that long-term outcomes at (survival rates and prevalence of comorbidities) between HIV+ and HIV- recipients were good and similar. These results support LT in PWH when clinically indicated.
This multicenter study showed that long-term outcomes (patient and graft survival rates) at 15 years between HIV+ and HIV- LT recipients (mostly with HCV infection) were comparable.
Comorbidities (e.g. cardiovascular), non-AIDS defining infections and cancer were common and similar in both groups. The prevalence of diabetes mellitus was more frequent in HIV- recipients.
Immuno-virological evolution of PWH was favorable with InSTI-based ART being the most common ART in recent years.
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