Date Published: July 30, 2012
Publisher: Hindawi Publishing Corporation
Author(s): E. Anadol, S. Beckebaum, K. Radecke, A. Paul, A. Zoufaly, M. Bickel, F. Hitzenbichler, T. Ganten, J. Kittner, M. Stoll, C. Berg, S. Manekeller, J. C. Kalff, T. Sauerbruch, J. K. Rockstroh, U. Spengler.
Objectives. This summary evaluates the outcomes of orthotopic liver transplantation (OLT) of HIV-positive patients in Germany. Methods. Retrospective chart analysis of HIV-positive patients, who had been liver-transplanted in Germany between July 1997 and July 2011. Results. 38 transplantations were performed in 32 patients at 9 German transplant centres. The reasons for OLT were end-stage liver disease (ESLD) and/or liver failure due to hepatitis C (HCV) (n = 19), hepatitis B (HBV) (n = 10), multiple viral infections of the liver (n = 2) and Budd-Chiari-Syndrome. In July 2011 19/32 (60%) of the transplanted patients were still alive with a median survival of 61 months (IQR (interquartile range): 41–86 months). 6 patients had died in the early post-transplantation period from septicaemia (n = 4), primary graft dysfunction (n = 1), and intrathoracal hemorrhage (n = 1). Later on 7 patients had died from septicaemia (n = 2), delayed graft failure (n = 2), recurrent HCC (n = 2), and renal failure (n = 1). Recurrent HBV infection was efficiently prevented in 11/12 patients; HCV reinfection occurred in all patients and contributed considerably to the overall mortality. Conclusions. Overall OLT is a feasible approach in HIV-infected patients with acceptable survival rates in Germany. Reinfection with HCV still remains a major clinical challenge in HIV/HCV coinfection after OLT.
The introduction of highly active antiretroviral therapy (HAART) in 1996 has enabled the control of human-immunodeficiency-virus (HIV)-infection in most patients and resulted in a marked decrease in opportunistic infections and an increase in life expectancy [1, 2]. Since HIV has now become a chronic disease, comorbidities are of increasing clinical importance. Among HIV-infected patients in Germany HCV coinfection rates range between 10 and 15% , and the prevalence of HBV surface antigen (HBs-Ag) is estimated to be 10% . Thus end-stage liver disease has become a prominent problem in these patients, and the demand for liver transplantation is increasing. Indeed, liver-associated mortality of HIV-coinfected subjects with viral hepatitis has become a leading cause of death in many countries [5, 6]. Despite recent advances in the treatment of chronic hepatitis B and hepatitis C, OLT remains the last resort for patients with decompensated liver cirrhosis. According to the 1993 consensus conference on indications for liver transplantation HIV infection was initially considered a contraindication, but the advent of HAART in 1996 improved prognosis of HIV-infected patients and has encouraged many transplant centers to accept selected HIV-positive candidates, and meanwhile more than 300 liver transplantations have been reported worldwide with overall promising outcomes [7–10].
After contacting all German transplant centers which had offered transplantation to HIV-infected patients, we conducted a retrospective observational cohort study.
Liver transplantation of HIV-infected patients is now considered a reasonable option in the HAART era. Multiple studies have reported promising results of HAART-treated HIV-infected patients with maximally suppressed viral loads, stable CD4 counts, and no significant increase in opportunistic infections after OLT [7, 12–15]. Here, we summarize the results of liver transplantation in HIV-positive patients from Germany. The overall mortality of liver-transplanted HIV-positive patients in Germany was 41% (13/32). These results are comparable to the 36% mortality rate reported by Spanish transplant centres ; the mortality rate in HIV-infected patients transplanted in the UK was 30% . Thus, outcomes of liver transplantation in Germany also support the concept that liver transplantation should be offered to selected HIV-positive patients.
Despite some regional differences in the outcome of transplanted HIV-infected patients in Germany, the overall mortality does not differ from that of other European countries. This favorable outcome with acceptable survival rates justifies the strategy to offer liver transplantation to HIV-infected patients with fulminant hepatic failure and end-stage liver disease. The outcome of this option may be improved with better criteria for patient selection and posttransplant management of recurrent liver disease. Nevertheless, the care for such patients still requires a meticulous balance of complex interacting factors such as the choice of HAART, correct dose adjustments of immunosuppressive drugs, and the optimal timing of therapy.