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MELD is the Best Predictor of Pre-transplant Mortality in HIV-infected Liver Transplant Candidates???? NO
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Reported by Jules Levin
15th CROI, Feb 2008, Boston
from Jules: During the Q&A several from the audience commented at the microphone that other study, I think the Spanish study, found shorter survival time in HIV coinfected, a difference from this study. Why? Were sicker patients removed from the list. The speaker said the two studies were different patients. The Spanish study took all comers while this study was patients who made the transplant list. Ray Chung asked about post-transplant outcomes and the speaker said they are collecting the info but that it looks like post-transplant outcomes are worse for coinfected, but that data is preliminary, she said. I say, post-transplant outcome is more important and the study I emailed yesterday & will resend now shows worse survival & HCV recurrence in cinfected and says what I say, coinfected need to be considered earlier for transplant, they need different standard than monoinfected.
Aruna Subramanian*1, M Sulkowski1, B Barin2, D Stablein2, M Curry3, N Nissen4, L Dove5, M Roland6, P Stock7, and M Ragni8
1Johns Hopkins Univ, Baltimore, MD US; 2EMMES Corp, Rockville, MD, US; 3Beth Israel Deaconess Med Ctr, Boston, MA, US; 4Cedars-Sinai Med Ctr, Los Angeles, CA, US; 5Columbia Univ, New York, NY, US; 6California Dept of Publ Hlth, Sacramento, US; 7Univ of California, San Fransisco, US; and 8Univ of Pittsburgh, PA, US
Background: HIV infection is associated with rapid progression of liver disease and may influence outcomes in liver-transplant candidates. While the model for end stage liver disease (MELD) score is accepted as a reliable predictor of mortality in HIV-uninfected transplant candidates, factors that predict mortality have not been established in HIV-infected candidates.
Methods: HIV+ liver transplant candidates without hepatocellular carcinoma enrolled in the Solid Organ Multi-Site Transplant Study (HIVTR) were matched 1:5 with controls from the United Network of Organ Sharing (UNOS) on age, gender, race, time period, and hepatitis C virus (HCV) infection. Time to death was compared and predictors of pre-transplant mortality and elevation of MELD ≥25 were examined by proportional hazards models. Contrasts with controls were based on clustered sampling.
Results: Of 167 HIVTR subjects, 58 (34.7%) were transplanted and 24 (14.4%) died prior to transplant. The pre-transplant mortality rate of 24/167 (14.4%) was similar to that of UNOS controls, 88/792 (11.1%), p = 0.30; there was no difference between HCV/HIV co-infected subjects, 18/125 (14.4%) and HCV-infected UNOS controls, 62/592 (10.5%), p = 0.28. Cumulative incidence of death (p = 0.15), transplant (p = 0.43), and elevation of MELD ≥25 (p = 0.50) were similar for HIVTR and controls. In both groups baseline MELD was a significant predictor of pre-transplant mortality by proportional hazards model (HR 1.27; p <0.001), with sepsis and multiple organ system failure the main causes of death. In the HIVTR group, those who died had lower median CD4 count at enrollment (237 cells/mm3) than those transplanted (315 cells/mm3) or non-transplanted (264 cells/mm3), p = 0.027. The proportion with detectable HIV RNA did not differ between those who died 5/24 (21.4%), were transplanted 9/57 (16.2%), or not transplanted 6/84 (7.1%), p = 0.09; but detectable HIV RNA was associated with an increased hazard of death (HR = 3.18; p = 0.02) and faster progression to MELD ≥25 (HR = 2.79, p = 0.005). After controlling for CD4 count, detectable HIV RNA and HAART use at enrollment, the only significant predictor of mortality was baseline MELD (HR 1.28; p <0.001).
Conclusions: HIV+ liver transplant candidates have similar pre-transplant mortality characteristics as HIV- controls. While lower CD4 counts and detectable HIV RNA are associated with death, baseline MELD appears to be the only significant predictor of pre-transplant mortality in HIV-infected liver transplant candidates.
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