Liver and kidney transplants may be warranted for carefully selected HIV-positive patients, say researchers in the United States. Transplantation improved the chances of survival of HIV-positive patients with severe liver disease. Comparison with HIV-negative showed that in patients undergoing liver transplantation HIV-positive patients were more likely to experience organ rejection or dying, but the difference in risk for both these results was small.
"The modest increase in risk compared to HIV-negative recipients, as well as the absolute proportion of those who died, in comparison with other transplant populations, liver transplant support may be a viable option in carefully selected recipients," comment the authors.
"Kidney transplantation for HIV-positive patients brings similar results to HIV-negative patients homologs in up to approximately 5 years post-transplantation in all control analyzes."
About 2% of HIV patients will develop renal failure and end stage of liver disease and is increasingly a major cause of death in the HIV-infected population. This means that a growing proportion of HIV-positive patients will need a kidney or liver transplant. However, it has been questioned whether patients with HIV are good candidates for transplantation.
Therefore, researchers from San Francisco devised a study to determine whether the survival prognosis of transplanted patients was improved compared to outcomes among HIV-positive and transplant-negative patients in terms of organ loss and death. The study also examined whether other factors were associated with organ rejection and death in HIV patients, rates of infection and hospitalization, and the impact of transplantation on the key to HIV markers, including CD4 count and viral load.
The population of HIV-positive patients consisted of 125 hepatic transplants and 150 kidney transplants undergoing transplants between 2003 and 2010. Their results were compared to HIV-positive patients who were candidates for liver (n = 148) or kidney (n = 167) transplant recipients who received care at the same time but who did not receive a new organ. Patients who received a kidney transplant had a CD4 cell count above 100 cells / mm3 and undetectable HIV viral load; Patients with transplanted liver livers had CD4 counts above 200 cells / mm3 and undetectable viral load or the possibility of establishing viral control after transplantation.
Patients with liver and kidney transplanted were kept on observation for a mean period of 3,5 and 4,0 years, respectively. Candidates were monitored for about a year.
Transplantation was associated with a significant survival benefit (p <0,0001) for patients with more severe forms of liver disease (MELD score of at least fifteen) but not for patients with less severe liver disease or for recipient patients kidney transplantation.
Factors associated with increased risk of mortality for liver transplant recipients with dual transplantation included (mean 3,8 risk, 95% 1.6-8.8 confidence interval, p = 0,002), low pre-transplant body mass index or BMI (Age, donor age (HR 2,2 per decade, IC 95% 1,1 - 4,4, p = 0,03), and co-infection with hepatitis C virus, (HR 1.3, IC 95% 1,1 - 1,6, p = 0,01). The same factors were associated with organ loss.
Risk factors for increased risk of mortality among kidney transplant recipients included, age at transplant (HR 1,07 per decade, 95% 1.1 - 1.26, p = 0,01), and thymoglobulin therapy in the first week after the transplant (HR 3,5, IC 95% 1,3 - 9,1, p = 0,01). Treatment with this drug was also associated with organ rejection (p = 0,048).
Twelve AIDS-defining opportunistic infections (Cutaneous Kaposi's sarcoma, esophageal or bronchial candidiasis, and pneumocystosis) were observed in patients with liver transplantation and four of these individuals died and the causes of death were a multisystemic organ failure, an accident cerebral vascular disease and recurrent hepatitis C.
Three recipients of kidney transplantation had a recurrence of HIV-associated kidney disease. His CD4 count at the time of relapse varied between 0 and 770 cells / mm3.
Severe HIV-related infections were observed in 55% of liver and kidney 50% of recipients. Half occurred within the first six months after transplantation. For both liver and kidney recipients, most of these bacterial infections were (80% and 71%, respectively). HCV co-infection was associated with increased risk of infections for both groups of transplanted patients.
For liver patients there were some indications of post-transplant recovery in CD4 cell counts.
Over three years of follow-up, 20% of patients with liver and 16% of kidney patients experienced an increase in their HIV viral load to detectable levels. Most, however, subsequently reestablished viral control.
The risk of graft loss and death was compared between patients with HIV and HIV-negative patients. The researchers conducted four sets of comparison: unmatched, demographically paired demographically paired adjusted for risk score and risk-matched. HIV-negative patients were identified in the national databases. The median follow-up was approximately four years.
For recipient recipients, risk-matched and unparalleled analysis showed that HIV-positive patients had significant increases in marginally risk of organ rejection (p = 0,07 and ep = 0,52, respectively). All models showed that HIV positive patients receiving recipients had an increased risk of graft loss compared to controls.
HIV was not associated with an increased risk of death following renal transplantation. HIV positive patients recipients had an increased risk of death in the unmatched (p = 0,01), demographically paired (p = 0,01) and demographically matched the adjusted risk score (p = 0,01) models but not the risk model combined. "The absolute difference in the proportion of deaths was 6,7% in the risk of matching control analysis," note the researchers.
"These analyzes of renal support and liver transplantation as an option for carefully selected people with HIV infection, the authors conclude.
Posted by Michael Carter at: 11 February 2016 in Survival and outcome analysis that selected HIV-positive patients are good candidates for liver and kidney transplant. Translated by Cláudio Souza in 18 / 02 / 2016
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