Successful liver transplantation between HIV-positive donor and HIV-positive recipient

Last Updated: 2016-11-03

By Will Boggs MD

NEW YORK (Reuters Health) - Liver transplantation for hepatocellular carcinoma is feasible where both the donor and recipient are HIV-positive, according to a case report.

"Liver transplantation was always feasible, but this report suggests that it can be associated with a successful outcome," Dr. David Mutimer from University Hospitals NHS Foundation Trust, Birmingham, UK told Reuters Health by email. "In this case, we believe that the transmission of donor strain of HIV has not been associated with a poor outcome for the recipient. The donor HIV was readily suppressed using the same antivirals that had sustained the recipient prior to liver transplantation."

Liver grafts from HIV-positive individuals have been avoided because of concerns about HIV superinfection and transmitted drug resistance.

Dr. Mutimer's team presents a case of liver transplantation from an HIV-positive donor to a 47-year-old HIV-positive recipient co-infected with hepatitis C virus who required transplantation for a single hepatocellular carcinoma complicating hepatitis C cirrhosis.

The recipient's tumor increased in size while he was on the transplant waiting list, and he agreed to accept a liver from an HCV-positive, HIV-positive donor who had HIV viremia but undetectable HCV RNA.

The recipient, who also had hemophilia A, had an undetectable HIV viral load at the time of transplantation but experienced a rebound on day 2 after transplantation.

Rebound and donor sequences were virtually identical, according to the report online November 2 in The New England Journal of Medicine.

Resuppression of the recipient's viral load occurred within the first seven postoperative weeks without a change in his antiretroviral therapy (ART), and his viral load subsequently remained undetectable for the ensuing five years after transplantation, while he continued to receive immunosuppressive therapy with tacrolimus and mycophenolate. There has been no evidence of recurrent hepatocellular carcinoma.

HCV RNA was detected on day 16 after transplantation and the establishment of cirrhosis was confirmed by year three after transplantation. HCV RNA became undetectable during treatment with oral direct-acting antiviral agents, and the patient achieved a sustained virologic response.

"In this case, there was no difference in post-transplant management in comparison with the management of an HIV-positive recipient receiving an HIV-negative liver donation," Dr. Mutimer said.

"The early post-transplant rise in titer was donor-derived virus, not recipient strain," he explained. "This was one of the uncertainties about the use of positive donors, i.e., that a donor HIV strain might be highly resistant to HIV antivirals and that management of the HIV post-transplant might be more challenging. However, the range and potency of presently available HIV antivirals makes it unlikely that transmitted resistance would be associated with therapeutic failure in management of the post-transplant infection."

"The report should also remind physicians that HIV-positivity is not a contraindication to liver transplantation and that new HCV antivirals will transform the outcome of HIV/HCV co-infected liver transplant patients," Dr. Mutimer added.

SOURCE: http://bit.ly/2fgDVga

N Engl J Med 2016.