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      HIV and liver transplantation: The British Columbia experience, 2004 to 2013

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          Historically, HIV-positive individuals have not been considered to be candidates for liver transplantation due to the need for further immunosuppresion of these patients post-transplant, as well as other factors such as pharmacokinetic interactions between the necessary antiretroviral and immunosuppressant drugs. However, HIV-positive individuals with end-stage liver disease are now eligible for liver transplantation in British Columbia. The purpose of this study was to summarize the outcomes of HIV-positive individuals referred for liver transplanation in British Columbia.



          The demand for definitive management of end-stage organ disease in HIV-infected Canadians is growing. Until recently, despite international evidence of good clinical outcomes, HIV-infected Canadians with end-stage liver disease were ineligible for transplantation, except in British Columbia (BC), where the liver transplant program of BC Transplant has accepted these patients for referral, assessment, listing and provision of liver allograft. There is a need to evaluate the experience in BC to determine the issues surrounding liver transplantation in HIV-infected patients.


          The present study was a chart review of 28 HIV-infected patients who were referred to BC Transplant for liver transplantation between 2004 and 2013. Data regarding HIV and liver disease status, initial transplant assessment and clinical outcomes were collected.


          Most patients were BC residents and were assessed by the multidisciplinary team at the BC clinic. The majority had undetectable HIV viral loads, were receiving antiretroviral treatments and were infected with hepatitis C virus (n=16). The most common comorbidities were anxiety and mood disorders (n=4), and hemophilia (n=4). Of the patients eligible for transplantation, four were transplanted for autoimmune hepatitis (5.67 years post-transplant), nonalcoholic steatohepatitis (2.33 years), hepatitis C virus (2.25 years) and hepatitis B-delta virus coinfection (recent transplant). One patient died from acute renal failure while waiting for transplantation. Ten patients died during preassessment and 10 were unsuitable transplant candidates. The most common reason for unsuitability was stable disease not requiring transplantation (n=4).


          To date, interdisciplinary care and careful selection of patients have resulted in successful outcomes including the longest living HIV-infected post-liver transplant recipient in Canada.

          Translated abstract

          HISTORIQUE :

          La demande d’une prise en charge définitive des maladies organiques terminales chez les Canadiens infectés par le VIH est en hausse. Jusqu’à tout récemment, malgré des données internationales faisant foi de résultats cliniques positifs, les Canadiens atteints d’une maladie hépatique terminale infectés par le VIH n’étaient pas admissibles à une transplantation, sauf en Colombie-Britannique (C.-B.), où le programme de transplantations de BC Transplant les accepte en vue d’un aiguillage, d’une évaluation, de l’inscription sur la liste d’attente et de l’exécution d’une allogreffe du foie. L’évaluation de l’expérience de la C.-B. s’impose pour déterminer les enjeux entourant la transplantation hépatique chez les patients infectés par le VIH.

          MÉTHODOLOGIE :

          Les chercheurs ont procédé à l’étude des dossiers des 28 patients infectés par le VIH qui ont été orientés vers BC Transplant pour subir une transplantation hépatique entre 2004 et 2013. Ils ont colligé les données sur l’état du VIH et de la maladie hépatique, l’évaluation initiale de la transplantation et les résultats cliniques.

          RÉSULTATS :

          La plupart des patients étaient des habitants de la C.-B. qui avaient été évalués par l’équipe multidisciplinaire de la clinique de C.-B. La majorité présentait des charges virales indétectables du VIH, prenaient des antirétroviraux et étaient infectés par le virus de l’hépatite C (n=16). Les comorbidités les plus courantes étaient l’anxiété et les troubles des humeurs (n=4), ainsi que l’hémophilie (n=4). Parmi les patients admissibles à la transplantation, quatre ont subi une transplantation consécutive à une hépatite auto-immune (5,67 ans après la transplantation), à une stéatose hépatique non alcoolique (2,33 ans), à un virus de l’hépatite C (2,25 ans) et à une co-infection par l’hépatite B et le virus delta (transplantation récente). Un patient est décédé d’une insuffisance rénale aiguë alors qu’il était en attente de transplantation. Dix sont décédés pendant la préévaluation et dix n’étaient pas des candidats adéquats pour la transplantation. La principale raison de ne pas être un candidat adéquat était une maladie stable ne nécessitant pas de transplantation (n=4).

          CONCLUSIONS :

          Jusqu’à présent, les soins interdisciplinaires et une sélection attentive des patients permettent d’obtenir des résultats positifs, y compris la présence au Canada du greffé hépatique infecté par le VIH ayant vécu le plus longtemps depuis sa transplantation.

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          Most cited references 16

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          MELD score is an important predictor of pretransplantation mortality in HIV-infected liver transplant candidates.

          Human immunodeficiency virus (HIV) infection accelerates liver disease progression in patients with hepatitis C virus (HCV) and could shorten survival of those awaiting liver transplants. The Model for End-Stage Liver Disease (MELD) score predicts mortality in HIV-negative transplant candidates, but its reliability has not been established in HIV-positive candidates.
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            HIV infection and advanced age emerging epidemiological, clinical, and management issues.

            While the mean age of HIV/AIDS patients at first diagnosis is progressively rising, no updated epidemiological estimates, controlled clinical data, and randomized therapeutic trials, are available regarding clinical and laboratory response to antiretroviral therapy, safety of anti-HIV compounds and their associations, potential drug-drug interactions, short- and long-term toxicity, consequences on underlying disorders, or interactions with concomitant pharmacological regimens, in the elderly. The life expectancy of HIV-infected persons treated with highly active antiretroviral therapy (HAART) now approximates that of general population matched for age, while also AIDS definition itself has lost most of its epidemiological and clinical significance, thanks to the immunoreconstitution resulting from the large-scale use of potent HAART regimens. The increased survival of HIV-infected patients, the late recognition of other subjects with missed or delayed diagnosis are responsible for a further expected rise of mean age of HIV-infected individuals, so that the patient population aged 60-70 years or more is expected to increase in coming years. Unfortunately, the majority of therapeutic trials involving antiretroviral therapy, as well as antimicrobial chemoprophylaxis for AIDS-related opportunistic complications, have advanced age and/or concurrent end-organ disorders among main exclusion criteria, or the design of these studies does not allow to extrapolate data regarding older patients, compared with younger ones. The very limited data presently available seem to demonstrate that HAART has a virological efficacy in the elderly comparable with that of younger adults, but immunological recovery is often slower and blunted, although several studies clearly demonstrated that thymic function is preserved until late adult age. When facing an HIV-infected patient with advanced age, health care givers have to pay careful attention to eventual end-organ disorders, all possible pharmacological interactions, overlapping toxicity due to concurrent drug administration. All these issues may significantly interfere with HAART activity, patient's adherence to prescribed medications, and frequency and severity of untoward effects. The guidelines of antiretroviral therapy and those of treatment and prophylaxis of AIDS-related diseases deserve appropriate updates, paralleling the increasing mean age of HIV-infected population. Moreover, epidemiological figures need an increased focus on older age, while clinical trials specifically targeting on the elderly population are mandatory to have reliable data on all aspects of HAART administration in advanced age.
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              Renal transplantation in patients with HIV.

              HIV infection has been a major global health problem for almost three decades. With the introduction of highly active antiretroviral therapy in 1996, and the advent of effective prophylaxis and management of opportunistic infections, AIDS mortality has decreased markedly. In developed countries, this once fatal infection is now being treated as a chronic condition. As a result, rates of morbidity and mortality from other medical conditions leading to end-stage liver, kidney and heart disease are steadily increasing in individuals with HIV. Presence of HIV infection used to be viewed as a contraindication to transplantation for multiple reasons: concerns for exacerbation of an already immunocompromised state by administration of additional immunosuppressants; the use of a limited supply of donor organs with unknown long-term outcomes; and, the risk of viral transmission to the surgical and medical staff. This Review examines open questions on kidney transplantation in patients infected with HIV-1 and clinical strategies that have resulted in good outcomes. It also describes the clinical concerns associated with the treatment of renal transplant recipients with HIV.

                Author and article information

                Can J Infect Dis Med Microbiol
                Can J Infect Dis Med Microbiol
                The Canadian Journal of Infectious Diseases & Medical Microbiology
                Pulsus Group Inc
                May-Jun 2014
                : 25
                : 3
                : 159-162
                [1 ]Department of Surgery, University of Toronto, Toronto, Ontario;
                [2 ]Obstetrics and Gynecology, University of Toronto, Toronto, Ontario;
                [3 ]Division of AIDS, University of British Columbia;
                [4 ]Division of Gastroenterology, University of British Columbia;
                [5 ]BC Centre for Excellence in HIV/AIDS, Vancouver General Hospital, Vancouver, British Columbia
                [6 ]Liver Transplant Program, Vancouver General Hospital, Vancouver, British Columbia
                Author notes
                Correspondence: Dr Eric M Yoshida, Division of Gastroenterology, Vancouver General Hospital, Diamond Health Care Centre, 5th Floor, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9. Telephone 604-875-5371, fax 604-875-5447, e-mail eric.yoshida@ 123456vch.ca
                Copyright© 2014 Pulsus Group Inc. All rights reserved

                This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) ( http://creativecommons.org/licenses/by-nc/4.0/), which permits reuse, distribution and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes. For commercial reuse, contact support@ 123456pulsus.com

                Original Article

                hepatitis, hiv, liver, transplant


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