Liver transplant in people with HIV/HCV coinfection
In people with decompensated liver disease, a liver transplant is the final option. This is a major operation, and success rates vary. It is also complicated by a scarcity of donor organs that are available for transplant.
For many years, transplant services actively avoided liver transplants in HIV-positive people. This was due to several factors including discrimination from some surgeons, who did not want to operate on HIV-positive people. The poor long-term life expectancy for HIV-positive people before combination therapy meant that a donor organ would provide fewer years of additional life than it might to a person without HIV or other medical conditions. There were also concerns about using drugs to suppress the immune system that are an essential part of a transplant, in HIV-positive people.
The effectiveness of HIV drugs has changed this. HIV is no longer an exclusion criteria for a liver transplant.Centres in the UK, Spain, France and the United States have transplanted livers into HIV-positive people. Some centres have reported no significant difference in survival according to HIV status.
However, medical management remains complex, due to drug interactions between drugs used to suppress the immune system after the transplant and protease inhibitors, the risk of graft rejection, HCV reinfecting the new liver, and difficulty in tolerating HIV and HCV treatment after the transplant.
Only a few transplant centres in the UK have reported liver transplants in people with coinfection, and referral to one of these centres is essential.
The success is largely limited by recurrent HCV infection in the new liver. HCV infection progresses more rapidly in people with HIV coinfection, and their survival after hepatic decompensation is shorter that that of people with HCV alone. Some specialists suggest that people with coinfection should be referred to a transplant list at an earlier stage of disease than people with HCV monoinfection.
A list of specialist liver centres and transplant units in the UK is included on the British Liver Trust web site.