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Orthotopic Liver Transplantation in HIV-1-infected Patients in Spain: A Prospective Cohort Study of 50 Cases
José M Miró*1, M Montejo2, V Vargas3, A Rimola1, A Rafecas4, P Miralles5, J Fortún6, M Blanes7, J Torre-Cisneros8, J Pons9, and the Spanish OLT in HIV-Infected Patients Study Group
1Hosp Clin, Univ of Barcelona, Spain; 2Hosp de Cruces, Bilbao, Spain; 3Hosp Univ Vall d’Hebrón, Barcelona, Spain; 4Hosp Univ Bellvitge, Barcelona, Spain; 5Hosp Gen Univ Gregorio Marañón, Madrid, Spain; 6Hosp Ramón y Cajal, Madrid, Spain; 7Hosp La Fé, Valencia, Spain; 8Hosp Univ Reina Sofía, Córdoba, Spain; and 9Hosp Univ Virgen de la Arrixaca, Murcia, Spain
Background: The safety and efficacy of orthotic
liver transplant (OLT) in HIV-1-infected patients is currently being studied.
Methods:
Prospective cohort study of all Spanish
HIV-1-infected patients who underwent OLT. Inclusion criteria were: liver criteria for OLT were the same as for
the non-HIV-1-infected population; no previous HIV C events (CDC definition), except
tuberculosis, pre-OLT CD4 cell count >100 cells/mm3, and
undetectable plasma RNA HIV-1 viral load on combined ART, or detectable plasma viral
load off HAART with post-transplant suppression predicted; and no heroin or
cocaine abuse for the last 2 years and no alcohol abuse for the last 6 months..
Results: The first OLT in an HIV-1-infected patient in Spain was
performed in January 2002. Currently, 14 sites have performed 50 liver
transplants in 49 HIV-infected patients. Median (IQR) age was 40 (38 to 45)
years; 78% of recipients were male; and former drug use (72%) was the most
common HIV-1 risk factor. Hepatitis C virus (HCV)-related cirrhosis (96%) was
the leading indication for OLT. Pre-OLT Child-Pugh class was A, B or C in 6%, 50%,
and 44% of cases, respectively. Median (IQR) MELD was 14.5 (11 to 17). Pre-OLT ART
was given in all but 2 cases (non-nucleoside reverse transcriptase inhibitor [NNRTI]-based
HAART in 48%, and protease inhibitor [PI]-based HAART in 25% of patients).
Median (IQR) CD4 cell count pre-OLT was 275 (192 to 369) cells/mm3,
and all but 2 patients had undetectable plasma RNA HIV viral load. A cadaveric graft was given to 48 recipients, and a living
donor’s graft to 2. Immunosuppression therapy was the
standard in each center; none died due to surgery. Median (IQR) follow-up was
12 (5 to 24) months. One patient required a re-transplantation for hepatic
artery thrombosis; 48% of patients experienced acute rejection. All patients
received combination ART after OLT. Of the 10 patients who died (20%), 5 deaths
were HCV-related. Survival (95% confidence intervals) rates at 1, 2, and 3
years were 85% (70 to 93%), 75% (56 to 86%), and 66% (42 to 82%), respectively.
There was clinical or immunological HIV-1 progression in only 3 cases. Therapy
with peg-interferon + ribavirin was started in 16
cases. Sustained virological response was achieved in
2 (18%) of 11 evaluable patients
Conclusions: OLT is a safe and effective procedure at
mid-term for selected HIV-1-infected patients in the HAART era. However, HCV
re-infection is a major cause for concern.
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