HIV-positive patients have shorter survival periods while awaiting liver transplants

A new study on HIV-positive patients eligible for liver transplants found that their survival while waiting for a transplant is significantly shorter than patients who are HIV-negative. Other than infection, which caused many of the deaths, there appear to be no other factors that predict a poor outcome for these patients.

The results of this study appear in the November 2005 issue of Liver Transplantation, the official journal of the American Association for the Study of Liver Diseases (AASLD) and the International Liver Transplantation Society (ILTS). The journal is published on behalf of the societies by John Wiley & Sons, Inc. and is available online via Wiley InterScience.

HIV-positive patients progress more rapidly to end-stage liver disease (ESLD), a condition requiring transplant, but post-transplant survival has improved in recent years, possibly because of advances in antiretroviral therapy. However, some patients do not survive long enough to undergo a transplant. Led by Margaret V. Ragni at the University of Pittsburgh School of Medicine, researchers studied whether poorer survival prior to transplant is related to the severity of either liver disease or HIV disease in these patients.

A total of 58 patients who were HIV-positive with ESLD were evaluated for transplant eligibility at the University of Pittsburgh Medical Center between 1997 and 2002. These patients were followed, along with 1,359 HIV-negative patients who were also evaluated for transplant. Of the 58 HIV-positive patients, 48 percent died before a transplant was performed, compared with 16 percent of the HIV-negative group. In addition, the survival period was much shorter in the HIV-positive group (880 versus 1,427 days), but the severity of their ESLD was no worse than the HIV-negative group. More than half of the deaths in the HIV-positive patients were due to infection.

The findings indicate that the development of ESLD in HIV-positive patients is associated with a high risk of early death. Speculating as to why this is the case, the authors state that "when ESLD develops in an HIV-positive individual, the already defective host defense against infection attributed to HIV may be further weakened by the immune defects associated with liver failure, resulting in a greater vulnerability of the HIV-positive candidate to infection or sepsis [an infection in the blood]." They further suggest that patients with HIV infection should be evaluated for transplant earlier in the course of their ESLD, as they appear to be at greater risk for infection, and that studies on whether prophylactic antibiotics may have a role in preventing this scenario may be warranted. They conclude: "Until then, it would seem prudent to monitor HIV-positive transplant candidates very closely for early signs of infection, inform them of the potential risk for infection, and urge them to seek medical attention at the earliest signs or symptoms of infection."

In the same issue, an accompanying editorial by Peter G. Stock, of the Department of Surgery at the University of California in San Francisco, CA notes that the study is the first documentation of a more rapid demise of HIV-patients awaiting transplant, adding that the importance of early transplant referral for these patients cannot be underestimated. The author suggests that transplant referral for HIV-positive patients may be delayed because HIV infection is still perceived by physicians as a barrier to undergoing a transplant, and these patients may therefore not be encouraged to meet the necessary transplant prerequisites in a timely manner, such as abstaining from alcohol and narcotics. In addition, the time it takes for the various specialists caring for HIV patients to coordinate a referral to a transplant center may be partially responsible for the delay. Also, by the time liver function in HIV infected patients deteriorates enough to warrant a transplant, they may no longer meet other criteria. The author notes that additional organs for these patients might be obtained via living donor grafts, which is not without risks to both donor and recipient, or the use of high infectious risk donors, excluding those who are HIV-positive. Although there is some concern about HIV transmission during a transplant procedure, the author states that the risk is actually much lower than the risk of transmission of Hepatitis C virus through a needle-stick. He concludes that "synchronized multi-special care along with early referral will help to minimize the number of deaths on the waiting lists and facilitate excellent outcomes following liver transplantation in this deserving group of recipients."