HCV Co-Infection: Natural History
Wednesday, 1:30 - 3:30 pm
Background:† Morbidity and mortality from end-stage liver and kidney disease are increasingly important, but transplantation was of limited utility before the advent of HAART. We describe outcomes from the largest prospective study of liver and kidney transplantatopm in the HAART era.††
Methods:† Prospective, multi-site cohort of HIV-infected transplant recipients followed for patient and graft survival, HIV outcomes (opportunistic complications, CD4+ T-cell count, HIV RNA) and rejection. Subjects had CD4+ T-cell count > 100/200 (liver/kidney) and undetectable HIV RNA or prediction of full suppression (liver). Time to subject and graft failure and cumulative rejection were analyzed using the Kaplan-Meier technique.
Results:† From March 2000 until November 2003, 29 subjects received transplants (18 kidney, 11 liver):† 28 were male, median age was 45 (15 to 64) years; 16 were white, 10 African American, 2 Asian, and 1 Hispanic; 5 had a history of opportunistic infection (Kaposiís sarcoma, cytomegalovirus [CMV], Pneumocystic carinii pneumonia, cryptococcal meningitis, tuberculosis); 2 liver subjects had detectable pre-transplant HIV RNA; 6 liver and 5 kidney subjects had hepatitis C. There were 2 deaths at 7 and 15 months from recurrent HCV in liver subjects and 1 at 6 months from congestive heart failure in a kidney subject. The estimated 1-year survival rates were 94% (6) for kidney and 91% (9) for liver; the 2-year rate decreased to 80% (13) in liver recipients. There were 2 kidney graft losses at 8 days caused by rejection or vascular thrombosis. The kidney graft survival estimate, censoring death with graft function, was 89% (7). There was 1 liver graft loss at 7 weeks due to a small-for-size graft lesion. The 1-year liver graft survival estimate was 82% (12). There was 1 case each of CMV (liver) and Candida (kidney) esophagitis and 1 anal carcinoma (liver); none occurred in subjects with a history of opportunistic infections. There was no significant change in CD4+ T-cell count in kidney (60; 95% CI 102 to 221) or liver (51; 95% CI 187 to 290) subjects. The last HIV RNA was undetectable in all but 1 surviving subject. 12 kidney subjects had 1 or more rejection; 1-, 2-, and 3-year cumulative kidney rejection estimates are 51%, 67%, and 78% (12%).
Conclusions:† Good patient and graft survival, stable CD4+ T-cell and HIV RNA levels, and few HIV-associated complications in a select group of HIV-infected subjects suggest that liver and kidney transplant is safe and effective in this population. A larger study will compare outcomes in 275 subjects with HIV-uninfected recipients with special attention to HCV recurrence in liver subjects and to elucidating the mechanisms of rejection among kidney subjects.
Keywords: Transplantation; End-stage liver disease; End-stage renal disease