Study
Looks at Factors Affecting Survival of HIV/HCV Coinfected
Liver Transplant Recipients
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| SUMMARY:
While HIV/HCV
coinfected patients can have good outcomes
after liver transplantation, acute organ rejection
remains a risk factor and survival does not match
that of HIV negative people with hepatitis C virus
(HCV) alone, according to a study presented at
the 60th Annual Meeting of the American Association
for the Study of Liver Diseases (AASLD
2009) this month in Boston. |
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By
Liz Highleyman
Norah
Terrault and colleagues from transplant centers across the
U.S. compared 1 and 3 year post-transplant survival and
rates of severe hepatitis C recurrence in HIV/HCV
coinfected versus HCV
monoinfected liver transplant recipients, and identified
predictors of these outcomes.
Hepatitis
C is the most common indication for liver transplantation
among people with HIV, the investigators noted as background.
Prior studies suggest HIV
positive individuals have a higher rate of mortality
while on the donor liver waiting list and worse post-transplant
survival, but data from the U.S. are limited.
The
present analysis included all 81 HIV/HCV coinfected liver
transplant recipients in the multicenter HIVTR (Solid Organ
Transplantation in HIV) study cohort. For each case patient,
the researchers selected 1-3 HCV monoinfected control subjects
(total 213) matched for type of transplant (single or dual
organ), presence or absence of hepatocellular
carcinoma, and study site. MELD scores were similar
in the 2 groups and similar proportions received liver grafts
from HCV-infected donors.
Participants
were followed for a media of about 1.5 years. Study endpoints
were patient and graft (new liver) survival as well as severe
HCV-related disease (cholestatic hepatitis, bridging fibrosis
or cirrhosis, or graft loss due to HCV).
Results
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HIV/HCV
coinfected patients were younger on average (50 vs 54
years) and received livers from younger donors (37 vs
42 years). |
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Coinfected
individuals were about twice as likely to have treated
acute rejection than HCV monoinfected patients (35%
vs 18%; P = 0.001). |
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Coinfected
patients also had a significantly higher likelihood
of receiving anti-HCV therapy than those with HCV alone
(38% vs 16%; P < 0.0001). |
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1-year
graft survival rates were 71% for HIV/HCV coinfected
patients compared with 86% for HCV monoinfected patients. |
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3-year
graft survival rates were 59% and 67%, respectively
(P = 0.01). |
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In
a multivariate analysis, the following factors were
significant predictors of graft survival: |
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Body
mass index (BMI) less than 21: hazard ratio (HR)
3.3 (P = 0.02). |
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Treated
acute rejection: HR 3.4 (P = 0.01); |
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Receiving
a liver from an HCV-infected donor: HR 3.4 (P
= 0.01); |
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Dual
kidney-liver transplant: HR 4.4 (P = 0.01); |
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Splenectomy
(spleen removal) (HR 4.4; P = 0.07) and use of tacrolimus
(Prograf) rather than cyclosporine as an initial immunosuppressive
drug to prevent graft rejection (HR 2.5; P = 0.10) were
of borderline statistical significance. |
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The
1-year cumulative incidence of severe HCV-related liver
disease was 18% among HIV/HCV coinfected recipients
compared with 8% among HCV monoinfected patients (P
= 0.19). |
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The
only significant predictor of severe HCV recurrence
was treated acute rejection; HIV status positively but
not significantly associated (HR 1.7; P = 0.16). |
Based
on these findings, the investigators concluded, "Patient
and graft survival were lower in [HIV/HCV] coinfected liver
transplant patients than HCV monoinfected patients, but
the key predictor of graft loss and severe HCV disease was
treated acute rejection."
They
added that, "These results support liver transplant
in coinfected patients, but highlight the need for better
markers of immune activation-suppression in this population,
and suggest that dual kidney-liver transplants, low BMI,
and use of HCV positive donors may confer a higher risk
of poor outcome."
University
of California-San Francisco, San Francisco, CA; EMMES Corporation,
Rockville, MD; Mt. Sinai School of Medicine, New York, NY;
Cedars Sinai Medical Center, Los Angeles, CA; Beth Israel
Deaconess Medical Center, Boston, MA; University of Pittsburgh,
Pittsburgh, PA; Rush University, Chicago, IL; Columbia University,
New York, NY; University of Miami, Miami, FL; Georgetown
Medical Center, San Diego, CA; University of Pennsylvania,
Philadelphia, PA; Northwestern University, Chicago, IL;
University of Cincinnati, Cincinnati, OH; Cleveland Clinic,
Cleveland, OH; University of Chicago, Chicago, IL; Tulane
University, New Orleans, LA; Johns Hopkins University, Baltimore,
MD; University of Virginia, Charlottesville, VA.
11/13/09
Reference
N
Terrault, B Barin, TD Schiano, and others. Survival and
Risk of Severe Hepatitis C Virus (HCV) Recurrence in Liver
Transplant (LT) Recipients Coinfected with Human Immunodeficiency
Virus (HIV) and HCV. 60th Annual Meeting of the American
Association for the Study of Liver Diseases (AASLD 2009).
Boston. October 30-November 1, 2009. Abstract 195.
