Highly active antiretroviral therapy has produced dramatic reductions in morbidity and mortality rates associated with Human Immunodeficiency Virus (HIV) infection in the United States [1,2]. However, the improved survival rate has lead to long-term complications in comorbid conditions with viral hepatitis and drug toxicities associated with highly active antiretroviral therapy. As a result, the incidence and prevalence of patients infected with HIV+ suffering from end-stage liver disease have markedly increased . Since 1996, hospital admissions secondary to chronic viral hepatitis in HIV+ patients have increased from 9 to 16%, while mortality in HIV+ patients with end-stage liver disease have also increased, 9 to 45% . Currently the most common cause of death in HIV+ patients is related to complications with end-stage liver disease . The management of end-stage liver disease is often limited to orthotopic liver transplantation, of which is considered a relative or absolute contraindication in HIV+ patients . Orthotopic liver transplantation is considered a standard therapeutic modality for the management of nearly all end-stage liver diseases, but not HIV+ patients. Many biased exclusionary reasons such as fear of consequential disease progression as related to pharmacological therapy and disease progression, funding and insurer denials, and organ donor shortages often preclude HIV+ candidates from this life saving treatment. Despite these exclusionary alibis, the United Network for Organ Sharing reports 40 cases of HIV+ orthotopic liver transplantation done in the past 3 years. Many of these cases are not reported in the literature. In this review we will evaluate the medical and ethical aspects of liver transplantation in the population infected with HIV+ suffering from end stage liver disease. We report the results of a series of patients with human immunodeficiency virus (HIV) coinfected with hepatitis B virus or hepatitis C virus and decompensated cirrhosis receiving orthotopic liver transplantation (OLT). Seven HIV+ patients with decompensated cirrhosis coinfected with hepatitis B virus or hepatitis C virus were listed for orthotopic liver transplantation according to United Network for Organ Sharing criteria. The patient demographics include: five male and two female patients ranging from 43 to 52 years with an average age of 49 years, 3/6 with hepatitis B virus, 3/6 patients with hepatitis C virus. Highly active antiretroviral therapy regimen was administered to 6/7 patients. Viral loads were less than 50 copies in six patients, and CD 4 counts were higher than 100. One patient presented with fulminant hepatitic failure. Six patients successfully received orthotopic liver transplantation while one patient succumbed to sepsis awaiting orthotopic liver transplantation. Three patients suffered acute rejection and were successfully treated with steroids, one of which required OKT-3. Tacrolimus toxicity associated with highly active antiretroviral therapy regimen, protease inhibitor related, developed in two patients. All patients were treated with highly active antiretroviral therapy regimens with undetectable viral loads and CD 4 counts higher than 400. There are no developments of opportunistic infections amongst this group of patients. The survival rates range from 10 to 39 months. Although these results are preliminary, they suggest that HIV+ patients coinfected with hepatitis B virus or hepatitis C virus suffering from end stage liver disease are suitable candidates for orthotopic liver transplantation.
ASJC Scopus subject areas
- Immunology and Allergy