HIVHCV Coinfected Patients Need Access to Liver Transplantation

1
HIV/HCV Co-infected Patients Need Access to Liver
Transplantation

• Sean Koppe, MD
• Joseph Ahn, MD
• Patrick Lynch, MD

2
Position Statement

• Since HAART therapy, there is growing need for
  liver transplants in HIV() patients as they live
  longer from their HIV and suffer increasing
  morbidity and mortality from their liver disease
• To date, preliminary data suggests HIV/HCV
  co-infected patients do as well as HCV
  mono-infected patients after transplant
• HIV() patients deserve access to transplant
  similar to patients with other chronic illness

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Need for Transplant

• 30 HIV patients are co-infected with HCV
  Sulkowski MS, et al. JAMA 2002288199-206
• 80 of hemophiliacs are HIV/HCV co-infected
  Ragni MV, et al. J Infect Dis. 2001 Apr
  1183(7)1112-5

4
Need for Transplant

• HIV accelerates the progression to cirrhosis in
  HCV patients
• Mean interval from time of acquisition of HCV to
  cirrhosis was 6.9 yrs in HIV() vs. 23.2 yrs in
  HIV(-) Soto B, et al. J Hepatol. 1997
  Jan26(1)1-5.
• Relative risk of death from ESLD in HIV()/HCV()
  hemophiliacs was 3.81 compared HIV(-)/HCV()
  hemophiliacs Ragni MV, et al. J Infect Dis. 2001
  Apr 1183(7)1112-5

5
Need for Transplant

• In the era of HAART, HIV patients are surviving
  their HIV but dying from their liver disease
• ESLD has risen as a cause of death in
  hospitalized HIV patients
• 11.5 deaths due to ESLD 1991 vs. 50 deaths due
  to ESLD in 1998-9 Bica I, et al. Clin Infect Dis
  200132492-497

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HIV() Patients Do Well After Liver Transplant

• Data from pre-HAART era is irrelevant
• HIV() patients have comparable outcomes to age
  and sex matched HIV(-) patients Ragni MV J
  Infect Dis. 2003 Nov 15188(10)1412-20.
• 12 mos 87.1 vs. 86.6
• 24 mos 72.8 vs. 81.6 (p0.365)
• 36 mos 72.8 vs. 77.9

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HIV() Patients Do Well After Liver Transplant
Fung J, et al. Liver Transpl 200410S39-S53
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HIV() Patients Do Well After Liver Transplant

• There is NO evidence for increased opportunistic
  infections
• There is NO evidence for worsening of HIV
• There is NO evidence for accelerated HCV
  recurrence or HCV related graft failure

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Transplantation of HIV/HCV Patients is Ongoing

• NIH agrees that transplantation of HIV/HCV
  patients is important and has funded a
  multi-center trial enrolling 125 HIV() liver
  transplant recipients and 150 HIV() kidney
  transplant recipients.
• Optimal use of HAART and immunosuppressive
  regimens and optimal selection of patients needs
  to be determined

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Conclusion

• HIV/HCV co-infected patients should not be denied
  access to liver transplantation
• Preliminary data suggests HIV/HCV patients do
  well post-transplant
• HIV patients with stable disease should be
  considered to have a chronic illness and deserve
  consideration for transplant