Living-donor liver transplantation in an HIV-positive patient with hemophilia.

Abstract

A better outcome after liver transplantation has been reported for human immunodeficiency virus (HIV)-positive patients who receive highly active anti-retroviral therapy (1). However, there is still some controversy regarding the use of a scarce resource (cadavers) for HIV-positive patients (2). The patient was a 41-year-old man with hepatitis C virus (HCV) cirrhosis. He was diagnosed with hemophilia B at age 6. He was infected with HIV, probably from factor IX concentrate. Lamivudine, saquinavir, and stavudine were administered in 1997 when the patient’s CD4 lymphocyte count was 104/μL and his HIV RNA, by polymerase chain reaction, was 1.5×103 copies/mL. Esophageal variceal bleeding, in 1993, and progressive jaundice and hepatic encephalopathy led to living-donor liver transplantation (LDLT). Laboratory studies revealed platelets 21,000/μL, alanine transaminase 67 IU/L (normal range, <40), bilirubin 4.1 mg/dL (0.3 to 1.3 mg/dL), prothrombin time 17.6 seconds, and Factor IX 4% of the standard. Computerized tomographic scanning confirmed cirrhosis and portal hypertension. The HCV RNA count was 1.3×104 Eq/mL, with a genotype of 2a. The CD4 lymphocyte count was 119/μl (24%), and the HIV RNA by PCR was fewer than 50 copies/mL. The donor was the patient’s healthy, 48-year-old brother. His right liver was harvested and implanted by the standard method (3). The total amount of blood loss in the donor operation was 340 mL, which was replaced by 300 mL of autologous blood. The recipient’s Factor IX level was monitored, and 6000 U of recombinant factor was infused to keep above 80% of the standard. However, it was more difficult than usual to maintain adequate hemostasis during the operation. A total of 37 U of packed red cells, 180 U of fresh frozen plasma, and 120 U of platelets were infused during the 19-hour procedure. The postoperative course of the donor was uneventful. The donor was discharged 10 days after the operation. The recipient had complications as a result of transient myocardial dysfunction, renal failure, herpes zoster infection, and pneumonia. Myocardial dysfunction was suspected to be caused by tacrolimus, which was switched to cyclosporine A on the fourth postoperative day. The patient required supportive care that included mechanical ventilation, inotropic support, and hemodialysis for cardiac and subsequent renal dysfunction. Herpes zoster infection and pneumonia responded to ganciclovir and antibiotics. No Factor IX was required after the operation. Two months after the operation, interferon alfa and ribavirin were administered for HCV infection. HCV was eradicated 2 weeks after treatment, which has been continued to prevent relapse (Fig. 1A). The HIV viral load has remained negative after the operation, and CD4 increased gradually and reached 236/μL by the 126th postoperative day (Fig. 1B). Highly reactive anti-retroviral therapy has not yet been started. Figure 1: Clinical course after transplantation. HCV (A) and HIV (B) viral load before and during the first 20 weeks after liver transplantation.It is our social duty to save patients with hemophilia who are infected with HIV and HCV, which were transmitted through clotting factor concentrates. LDLT for adult patients has become an alternative to expand the donor pool since our first success (4). LDLT should be considered as an option to save the patient whose status is dismal. Yasuhiko Sugawara Takao Ohkubo Masatoshi Makuuchi Satoshi Kimura Yuji Morisawa Natsuo Tachikawa Shincihi Oka