Monday, April 27, 2009

HIV No Barrier to Liver Transplant

By Michael Smith, North American Correspondent, MedPage Today
Published: April 24, 2009
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

TORONTO, April 24 -- People with HIV do just as well as others after a liver transplant -- as long as they don't have hepatitis C as well, researchers said in Copenhagen.

In one of the few studies with data on long-term outcomes, those with HIV had one- and five-year survival rates of 86.5% and 74% respectively, according to John O'Grady, M.D., of Kings College Hospital in London.

By comparison, HIV-negative liver transplant patients in the prospective UK Transplant Database had rates of 87.1% and 78%, which were not significantly different, Dr. O'Grady reported at the annual meeting of the European Association for the Study of the Liver.

"In terms of HIV, the clinical guidance is that theses patients do very well, (and) they should be considered for transplant in the normal way," he said. "They don't present any particular different clinical problem than the general liver transplant population."

On the other hand, he said, patients with both HIV and hepatitis C are a significantly greater challenge.

"They need to be counseled that severe recurrence of hepatitis may be a problem after the transplant," he said, adding that he and other specialists are anxiously awaiting new medications.

"We are desperate to get the newer agents, evolving agents, tested in this population at an early stage, because they have clearly an urgent need for drugs to control hepatitis C replication," Dr. O'Grady said.

Dr. O'Grady and his colleagues analyzed outcomes of all patients having a liver transplant in the U.K. from March 1994 through April 2008.

The database includes 33 people with HIV, 847 with hepatitis C, and 5,435 HIV-negative patients. Of the HIV-positive patients, 22 also had hepatitis C.

The researchers compared patients with both HIV and hepatitis C, those with HIV, and those with hepatitis C only.

The analysis found that:

  • Model for End Stage Liver Disease (MELD) scores were comparable between the three groups.

  • Patients with both viruses lived, on average, for 29 months post-transplant, compared with 47.7 months for those with hepatitis C only, a difference that was significant at P=0.04.

  • One- and five-year survival rates were 73% and 53% for those with both diseases, compared with 100% and 100% for those with just HIV, and 87% and 69% for those with just hepatitis C. The differences were significant at P=0.04.

Interestingly, despite the promising one- and five-year survival rates, patients with HIV had a mean post-transplant survival rate of 44 months compared with 57.1 months for HIV-negative patients, a difference that was significant at P=0.0001.

Dr. O'Grady said that difference is probably an artifact of the changing face of HIV -- the analysis included only a few patients transplanted early in the HIV pandemic, who tended to do very poorly.

In a univariate analysis, hepatitis C infection was a significant predictor of death after transplant in HIV-positive patients, with an odds ratio of 10 and a 95% confidence interval from 1.03 to 97.04.

But in a multivariate logistic regression model, the effect of hepatitis C was not independent of other covariates, such as MELD score and recipient and donor ages.

The researchers did not report study support or conflicts.

Primary source: European Association for the Study of Liver
Source reference:
Joshi D, et al "UK liver transplant experience of HIV: Long term outcomes" EASL 2009;

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