Solid organ transplant in HIV/hepatitis co-infected patients

HIV-positive patients have previously been excluded from liver or kidney transplant operations due largely to concerns of allocation of limited resources for patients assumed to have a poor prognosis and concerns of accelerating HIV progression from use of immunosuppressive drugs.

The wide extent of co-infection in both Europe and the US has been well documented and liver failure is now amongst the highest causes of HIV-related mortality and morbidity. It was therefore encouraging to see a poster reporting eight cases of liver transplants carried out at Kings College, London between 1995-2000. [1]

Four patients had end stage liver disease (ESLD) related to HCV (3 with haemophilia A). Two patients had acute liver failure; one related to HBV, one to non-A non-B. One had chronic ESLD due to HBV.

All patients survived the immediate post-transplant period, although the four patients with HCV died from complications from recurrent HCV infection 3-25 months post transplant despite use of interferon alpha plus ribavirin treatment in two of the cases.

The four patients with HBV all survive with good graft function at 33, 13, 3 and 1 month post transplant. HBV is treated with lamivudine (3TC) and hepatitis B immunoglobulin. No HIV complication have been reported in these patients who continue HAART treatment with undetectable viral loads and CD4 counts >200 cells/mm3.

As improved treatments for HCV and HBV continue to develop, often incidentally with overlapping activity against HIV, the study notes that HIV-infection should not be seen as an absolute contraindication for liver transplantation.

These results were supported in a report of five patients treated at the University of California, San Francisco with ESLD (n=1) or end stage kidney disease (n=4). The patient coinfected with HCV required a re-transplantation (small for size graft lesion) and responded to interferon alpha plus ribavirin treatment. Two episodes of reversible kidney rejection (plus one currently being treated) were reported. All patients are alive at a median of 138 days (62-216 days) post transplant. [2]