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Post-Transplant Survival Lower With HIV and HCV-1 Than With HCV-1 Alone
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CROI 2014, March 3-6, 2014, Boston
Mark Mascolini
HIV-positive people with HCV genotype 1 had significantly shorter 5-year survival after liver transplant than people infected with HCV-1 alone, according to results of a 900-person case-control comparison in Spain [1]. Survival did not differ between people with and without HIV among those with HCV genotype 2, 3, or 4. The investigators believe direct-acting antivirals (DAAs) will improve sustained virologic response (SVR) rates before transplant in people with genotype 1 and therefore survival.
Jose Miro, Christian Manzardo (University of Barcelona), and collaborators throughout Spain noted that previous research found 50% to 55% survival 5 years after liver transplant in people coinfected with HIV and HCV, rates lower than in people infected with HCV alone. To further the understanding of post-transplant survival with HCV/HIV, they compared survival in 215 coinfected people and 676 HCV-only people who had HCV replication at the time of transplant. They matched the HIV-negative group to the coinfected group for transplant center, year of transplant (+/- 1 year), age (+/- 12 years), gender, HBV coinfection, and hepatocellular carcinoma.
Men accounted for about 80% of participants among both HIV-positive cases and HIV-negative controls. Despite matching, median age was significantly younger in the coinfected group (45 versus 49, P < 0.05), and a significantly higher proportion of coinfected people also had HBV infection (7.4% versus 1.3%, P < 0.05). The HCV/HIV group had a lower proportion of people with HCV genotype 1 (56% versus 72%, P < 0.05), a higher proportion with genotype 4 (17% versus 5%, P < 0.05), and a higher proportion with genotype 2 or 3 (24% versus 13%, P < 0.05).
Five-year survival among people with HCV genotypes 2 or 3 did not differ significantly between the coinfected group and the HCV-only group (69% versus 77%, P = 0.17). Nor did survival differ significantly between HIV-infected and uninfected people with HCV genotype 4 (53% versus 68%, P = 0.42).
But overall 5-year survival was significantly lower in the coinfected group than in the HCV-only group (50.6% versus 67.6%, P < 0.0001) because of lower survival in the HCV/HIV group infected with genotype 1 (40.0% versus 66.7%, P < 0.001). Among people HCV RNA-negative at transplant, 5-year survival was higher overall and nonsignificantly lower in the coinfected group (73% versus 84%, P = 0.22).
Among people with HCV/HIV coinfection, infection with genotype 1 doubled the risk of death. Higher Model for End-Stage Liver Disease (MELD) score and high HCV load also independently raised chances of death. Transplantation at a site that did more than 10 transplants and HIV load below 200 copies improved chances of survival, as indicated by the following adjusted hazard ratios (aHR) (and 95% confidence intervals):
Raised chance of post-transplant death:
-- HCV genotype 1: aHR 1.94 (1.19 to 3.14), P = 0.007
-- Each unit higher MELD: aHR 1.14 (1.00 to 1.07), P = 0.039
-- HCV RNA above 400,000 units: aHR 1.62 (1.03 to 2.57), P = 0.038
Lowered chance of post-transplant death:
-- More than 10 transplants at site: aHR 0.58 (0.37 to 0.94), P = 0.025
-- HIV RNA below 200 copies: aHR 0.47 (0.24 to 0.90), P = 0.023
Although among genotype 1 patients post-transplant survival was significantly lower in HCV/HIV-coinfected people than in those infected only with HCV, the researchers propose that genotype 1 patients "should not be excluded from liver transplantation" because DAA therapy can often control their HCV replication. And coinfected people HCV RNA-negative at transplant did not differ in survival from HIV-negative people.
The complexity of post-transplant care probably explains the association between transplant site experience and survival and suggested to these researchers that liver transplants in people with HCV and HIV should be done only at experienced sites.
Reference
1. Miro JM, Montejo M, Blanes M, et al. Outcome of 215 HCV/HIV-coinfected liver transplant recipients: a prospective multicenter study. CROI 2014. Conference on Retroviruses and Opportunistic Infections. March 3-6, 2014. Boston. Abstract 648.
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