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Chapter 18: Liver Transplantation in HIV-Infected Patients

Catherine Choi; Nikolaos T. Pyrsopoulos

INTRODUCTION

  • With the introduction of combined antiretroviral therapy (cART), human immunodeficiency virus (HIV) is now considered a chronic illness and no longer considered an absolute contraindication to liver transplantation (LT).1

  • As HIV-infected patients live longer, liver transplantation is a reasonable option in those with advanced liver disease in the ART era. Multiple studies have shown promising results in ART-treated patients with suppressed HIV RNA, stable CD4 counts, and no significant increase in opportunistic infections after LT. See Table 18-1 for a generally accepted description for stable disease.2

TABLE 18-1Suggested Inclusion Criteria for LT in HIV-Infected Individuals
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TABLE 18-1 Suggested Inclusion Criteria for LT in HIV-Infected Individuals

  • CD4 cell count > 100 cells/µL without history of opportunistic infections

  • CD4 cell count > 200 cells/µL during 3 months prior to LT if history of opportunistic infections or AIDS-defining malignancies

  • Undetectable HIV viral load in blood for patients on C-ART

  • If detectable viral load due to intolerance of C-ART, previous documentation of efficacious therapy or genotype/phenotypic resistance test documenting available post-LT C-ART options

  • Compliance to a stable C-ART, and appropriate follow-up visits with providers experienced in the HIV management

    No active (less than 1 year) opportunistic infections, no wasting syndrome or severe malnutrition

    Ready access to therapeutic drug monitoring of immunosuppressive regimen

  • There is no history of progressive multifocal leukoencephalopathy, chronic intestinal cryptosporidiosis (greater than 1 month duration), lymphoma or other neoplasm unless an adequate disease-free period is documenteda

LT: Liver transplantation, C-ART: Combined antiretroviral therapy; HIV: Human Immunodeficiency virus.

Most centers refer to the criteria set by the American Society of Transplantation (AST). There can be slight differences in the criteria due to center-specific guidelines as well as differences in the criteria between the U.S. and Europe.

Data from recent guidelines from AST Infectious Diseases Community of Diseases and a review article by Baccarani et al. Blumberg EA, Rogers CC. Solid organ transplantation in the HIV-infected patient: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clinical Transplantation. 2019;33(9). Baccarani U, Righi E, Adani GL, et al. Pros and cons of liver transplantation in human immunodeficiency virus infected recipients. World J Gastroenterol. 2014;20(18):5353-5362.

aCriterion abstracted from the review article by Baccarani, et al only.

PRETRANSPLANTATION EVALUATION

  • Careful selection of HIV-infected patients to receive LT is important to ensure safety. Eligibility criteria for LT in HIV-infected patients are evolving to carefully select those with relatively intact immune systems and successfully suppressed viral load.1,3,4 Selection criteria for LT in HIV-positive individuals are listed in Table 18-1.

  • HIV-infected patients have significantly shorter survival compared with HIV-negative patients. HIV-infected patients should be listed and transplanted as soon as possible, given a poor outcome while on the waiting list.3

  • HIV/hepatitis C virus (HCV) coinfected patients should be referred for LT after the first episode of decompensated cirrhosis.5...

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