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Liver Transplantation in HIV and HCV Coinfected Patients
Reported by Jules Levin
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French researchers (abstract 259; Didier Samuel et al) from the Hospital Paul
Brosse in Villejuif, France reported on the results so far seen in 7 patients
with HCV/HIV coinfection who received liver transplants. Average age of the
patients was 40 and they underwent transplant between December 1999 and March
2002. All patients (6 men) had Child C cirrhosis, controlled HIV replication,
average CD4 count of 275, no prior opportunistic infections. For
immunosuppression to perform transplant Tacrolimus and steroids were used.
RESULTS. 3 patients received a domino graft (from a donor transplanted for
familial amyloidotic polyneuropathy); 2 a living related donor graft and 2 a
cdaver graft. 5 of the 7 are alive, and as the presenter said 4 are "alive
and well", but post transplant experience can have complications which are
described below. The average followup time for these patients is 12.8 months
(4-30 months). The longest a patient is alive who is doing well is 30 months.
In general transplant experience is that patients with hepatitis B have
better outcomes than patients with hepatitis C. 3 patients are doing
relatively well. The study presenter said 4 of the 7 patients have shown
dramatic improvement. 1 patient is in good condition at month 30 and is HCV
negative. a second patient has F1 fibrosis at month 12 of followup with low
or undetectable HIV RNA and in good condition. A third patient is in good
condition at month 18 of followup. Three patients are not doing well. Another
patient is alive with F3 fibrosis at month 14. Two patients died. One patient
died at month 22. And a second patient died at month 4 after developing
severe liver disease.
Although I thought presenter said there have been no opportunistic infections
in talk program abstract reports 1 patient had oesophageal candidosis.
Patients have been able to achieve adequate control of HIV after transplant.
5 patients had undetectable HIV viral load, transiently positive in one and
high in one after discontinuation of HAART.
Protease inhibitors and tacrolimus interaction was responsible for acute
rejection by low tacrolimus level in 1 and for toxic levels of tacrolimus in
1.
HCV recurrence occurred in all patients with a 1-2 log increase in HCV viral
load within the first 3 months post transplant. HCV acute hepatitis was seen
in all 7 patients. One patient developed a severe chronic hepatitis C
requiring combination therapy of interferon and ribavirin, which led to
complete antiviral response. 4 patients developed mixed lesions of
microvesicular steatosis, and of hepatitis C. One patient died of multiple
organ failure due to HAART toxicity and of hepatitis C at 4 months. Still,
study authors reported a significant improvement of quality of life and gain
of weight in 5 of 7 patients. The authors concluded (1) HAART toxicity and
HCV recurrence are the 2 main complications in this preliminary experience;
(2) Liver transplantation in HCV/HIV coinfection is feasible but requires a
cautious monitoring of HCV reinfection, of drug interactions and of
antiretroviral toxicity.
During the question and answer period following the presentation someone from
Kings College in London talked about their negative experience with
transplanation for HCV/HIV coinfected and expressed doubts about the
feasibility, but at the same time sites including the University of
Pittsburgh, U of Miami, and Michelle Roland at UCSF have reported from
preliminary results that HCV/HIV coinfected appear to have comparable
outcomes from transplantation as patients with only HCV. As I said above,
transplants in patients with HBV appear to have better outcomes than patients
with HCV.
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