Journal of Hepatology
Volume 48, Issue 5 , Pages 695-696, May 2008

Tenth Forum on Liver Transplantation:☆

Are HIV-infected patients candidates for liver transplantation?

Swiss HPB (Hepato-Pancreato-Biliary) Center, Department of Surgery, University Hospital Zürich, Raemistrasse 100, CH-8091 Zürich, Switzerland

published online 28 February 2008.

Article Outline

Abbreviations: AIDS, acquired immunodeficiency syndrome, MELD, model for end-stage liver disease, OLT, orthotopic liver transplantation, HIV, human immunodeficiency virus, IFN, interferon, NIH, National Institute of Health, HBV, hepatitis B virus, HCV, hepatitis C virus, DNA, deoxyribonucleic acid

 

Since 2005, we have published a series of “Forum on Liver Transplantation” covering a number of controversial topics ranging from issues related to hepatitis C [1], cancer [2], [3], [4], surgical aspects including the use of living [5] or “marginal” [6] donors, acute liver failure [7] or even on issues related to the best institutional setting providing an optimal framework, e.g., center approach, to treat patients with liver diseases [8]. Each forum was comprised of a series of 4–5 articles, in which established experts were selected to address a specific question on a controversial topic. Starting from the 10th forum, we will switch to a different format, whereby an expert (first author) will be responsible for a single article to coordinate the entire forum, with international colleagues chosen based on their scientific contribution to the field. In contrast to many other reviews, co-authorship with junior members in this new format will be avoided to present a “Forum” based on the sole opinion of “established” experts.

Forum 10, the first one of this new format, has been prepared by Didier Samuel, from Paul Brousse Hospital, Paris, whose task involved addressing the controversial issues of liver transplantation in the HIV-infected population. The topic is very timely due to the increasing prevalence of co-infection with hepatitis viruses B and C, the advent of new antiviral strategies, both against HIV and hepatitis B and C, and the increasing panel of available anti-rejection drugs after transplantation. Recent reports in this field justified this discussion with the aim to also highlight areas requiring further investigation.

Rainer Weber, from the University of Zürich, Switzerland, covers the epidemiology of the 32 millions of HIV-infected patients worldwide, highlighting that the search for a vaccine has failed so far, and that, unfortunately, there is still no credible expectation about when one will become available [9]. In a large cohort of patients, the most frequent cause of non-AIDS related deaths in this population was liver disease, related in more than three-quarters of cases to chronic hepatitis B and C co-infection [10]. Peter Stock from the University of California in San Francisco, USA, is the principal investigator of a large NIH sponsored study on the role of liver transplantation in HIV-infected patients. In a comprehensive discussion, Dr. Stock presents the criteria to optimally select patients for liver transplantation. Rigid rules such as a CD4+ counts >200cell/mL should be avoided, as the presence of portal hypertension with hypersplenism and the use of IFN therapy in HCV-infected patients may cause further decreases in CD4+ counts, unrelated to HIV infection [11]. Similarly, opportunistic infection, once considered as an absolute contraindication, must be evaluated in light of the chance for the patient to reconstitute an immune response with antiretroviral therapies and appropriate antibiotic treatment. On the other hand, care should be taken to avoid transplantation in a patient with very poor liver reserve, i.e., high MELD score, particularly in the HCV population. At this point, the single most important factor in dealing with these complex patients is the availability of a clinician experienced with the HIV positive population. Another controversial issue is the choice of the immunosuppressive regimen following OLT. This part, covered by Jean-Charles Duclos-Vallée, indicates that not much convincing data are currently available in this area. Two principles should, perhaps, trigger special attention: first, the avoidance of a rapid withdrawal of steroids [12], particularly in the HCV population, due to the evidence of accelerated fibrosis, and second, great care should be taken in managing potential interaction among antiviral and immunosuppressive drugs. Finally, Norah Terrault, from the University of California in San Francisco, USA, provides an excellent discussion related to the management of such patients before and after OLT. She emphasises the need for the early referral of co-infected HIV patients with hepatitis viruses B and C to transplant centers, as the severity of the disease and the nature of liver decompensation mostly influence the results of OLT in this population [13]. In HBV patients, the main pre-transplant strategy is to reach a low level of HBV DNA at the time of surgery, and in HCV patients, to prevent the rapid aggravation of the liver function (e.g. child C or high MELD score), which could be achieved, for example, by using a living donor.

I thank Didier Samuel for the excellent and critical coverage of this complex field with the help of international experts. I hope that this new format will help clinicians to better evaluate this difficult population of patients for OLT.

Back to Article Outline

References 

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  2. Clavien P-A. Hepatocellular carcinoma: where are the controversies?. [Editorial: Forum on Liver Transplantation] J Hepatol. 2005;42:556–557
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☆ The author declares that he does not have anything to disclose regarding funding from industries or conflict of interest with respect to this manuscript.

PII: S0168-8278(08)00127-X

doi:10.1016/j.jhep.2008.02.007

Journal of Hepatology
Volume 48, Issue 5 , Pages 695-696, May 2008

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