Management of end stage liver disease (ESLD): What is the current role of orthotopic liver transplantation (OLT)?
Introduction
End-stage liver disease (ESLD), mainly caused by hepatitis C virus (HCV), is becoming an important cause of death among human immunodeficiency virus-1 (HIV-1) infected patients in the highly active antiretroviral therapy (HAART) era [1]. Orthotopic liver transplantation (OLT) is the only therapeutic option for patients with ESLD. Until a few years ago, infection by HIV was an absolute contraindication to any type of transplant [2]. However, the spectacular improvement in prognosis observed in HIV-infected patients after the introduction of HAART in 1996 has meant that HIV infection by itself is not a contraindication for liver transplantation. This paper does not aim to provide an exhaustive review of the matter at hand, which has already been amply studied in other recent reviews [3], [4], [5], [6], [7]. Our objective is to define the criteria to select HIV-infected patients for OLT, taking into account that this field is evolving continuously and the indications for OLT or management of these patients may change as more evidence becomes available.
Section snippets
Experience of OLT in HIV infected patients in the HAART period (1996–2005)
Initial attempts at OLT in HIV infected patients before the introduction of HAART regimens (before 1996) provided very poor results. Putting together the most important case series published [8], [9], [10], [11], 3-year survival was only 44% (Table 1). Most patients died because of HIV-disease progression, being graft function normal in many cases. However, since the introduction of HAART in 1996, HIV infected recipients of liver transplantation have improved their short- and mid-term survival.
Magnitude of the problem in Europe
According to current estimates, there are around 540,000 HIV-infected patients in Western European countries [14]. Prevalence of HCV and HBV co-infection in European HIV-infected patients was 33 and 9%, respectively [15], [16]. So, the estimated number of HCV and HBV co-infected patients is around 180,000 and 49,000 cases, respectively. In a cross-sectional study performed in Spain [17], 8% of co-infected patients had clinical or histological criteria of cirrhosis and 17% of them met the
HIV criteria for including HIV-infected patients on the liver transplant waiting list
Most liver transplant groups are using similar criteria in the HAART era [4], [5], [6], [18]. Criteria concerning the liver disease are the same as for the non-HIV-infected population. Inclusion and exclusion criteria have been recently reviewed in the English guidelines for liver transplantation [18]. The main indication for OLT in HIV-infected patients being ESLD caused by HCV co-infection [4], [5], [6]. Less frequent indications were HBV co-infection (either acute or ESLD) and liver cancer.
Special considerations in HIV-infected patients
OLT in HIV-infected patients is a complex scenario that requires a multidisciplinary approach during the pre- and post-transplant periods [4], [5], [6], [19]. The team should include members from the liver transplant team (medical and surgical), infectious diseases and HIV specialists, a psychologist/psychiatrist, an expert on alcoholism and drug abuse, and a social worker.
Future research needs
There are several issues that should be explored in the future: (1) since survival is much shorter in HIV-co-infected patients, strategies to make OLT available sooner after patient assignment to this procedure should be underlined; (2) it is important to create a European or an International registry of cases, using standardized CRF in order to know the mid and long-term survival of OLT in HIV-infected patients and to compare it with the non-HIV-infected population; (3) to improve the
Acknowledgements
This document is dedicated to all our patients and has come about thanks to the collaboration of many people and institutions.
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2015, Clinics in Liver DiseaseCitation Excerpt :HIV/HCV co-infection leads to particularly aggressive liver disease with more rapid progression to hepatic fibrosis.49 The generally accepted immunologic criteria for LT listing in HIV-infected patients is CD4 count greater than 100 cells per cubic millimeter, ideally without prior acquired immunodeficiency syndrome–defining opportunistic infections and an undetectable HIV viral load (<50 copies per milliliter) at the time of transplant.50 The accumulated evidence has shown that HIV-infected patients with non–HCV-related end-stage liver disease have comparable survival rates after LT to those of other transplant recipients.51
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- 1
The members of the Hospital Clinic OLT in HIV Working Group are: J.M. Miró, A. Rimola, A. Moreno, M. Laguno, J.L. Blanco, J. Mallolas, C. Cervera, M. Tuset, M. Monras, N. Freixa, J. Blanch, C. Lanaspa, E. de Lazzari, J.C. García-Valdecasas, J.M. Gatell; C. Tural and D. Fuster (Hospital Germans Trías i Pujol, Badalona), J. Murillas and E. Moitinho (Hospital Son Dureta, Palma de Mallorca).