Opportunistic infections after liver transplantation in patients infected with human immunodeficiency virus

Abstract

We read with great interest the article by Moreno et al. entitled “Epidemiology and Outcomes of Infections in Human Immunodeficiency Virus/Hepatitis C Virus–Coinfected Liver Transplant Recipients: A Spanish Foundation for the Investigation and Prevention of Acquired Immunodeficiency Syndrome/Spanish Group for the Study of Acquired Immunodeficiency Syndrome Prospective Cohort Study.”1 Surprisingly, in a cohort of 84 consecutive patients coinfected with human immunodeficiency virus (HIV) and hepatitis C virus who underwent liver transplantation (LT) at 17 Spanish centers, the authors reported that 9 patients (11%) experienced 10 episodes of opportunistic infections with a high mortality rate of 44%. These opportunistic infections included 2 episodes of zygomycosis, 1 episode of invasive aspergillosis, 2 episodes of cytomegalovirus disease, 2 episodes of esophageal candidiasis (both in the same patient), 2 episodes of tuberculosis, and 1 episode of Pneumocystis jiroveci pneumonia. During a plenary session at the 2011 meeting of the American Association for the Study of Liver Diseases, we described our experience at a single center in France with 105 HIV-infected patients who underwent transplantation between December 1999 and March 2010.2 Only 5 patients (4.8%) developed opportunistic infections after LT: esophageal candidiasis (2 patients), tuberculosis of the lymph nodes (1 patient), cytomegalovirus colitis (1 patient), and an atypical mycobacterial infection (1 patient). Two of these 5 patients developed opportunistic infections because of an uncontrolled HIV infection due to noncompliance with their antiretroviral regimen, whereas 1 patient experienced an opportunistic infection similar to one that was recorded in his medical history long before LT. Data for the patients who developed these opportunistic infections are shown in Table 1. All these infections were treated with specific therapies, and none of the patients died. However, other major published series have not recorded such high rates of opportunistic complications.3, 4 There may be several reasons for these discrepancies in the incidence of opportunistic infections between different centers. First, the local epidemiology of tuberculosis and fungal infections may be one explanation; a large number of the patients 18/84 (21%) who were accepted for LT at the Spanish centers had a history of opportunistic infections.1 Second, there may have been differences in the post-LT antimicrobial prophylaxis. Finally, the level of immunosuppression induced by immunosuppressive therapy could also be an important factor. Concerning the last point, the authors reported a high rate of acute rejection (32/84 or 38%) and the use of boluses in 13 of those patients (41%). This observation highlights the crucial importance and inherent problems of achieving ideal immunosuppressive management in HIV-infected patients during the immediate post-LT period for preventing not only opportunistic complications but also the recurrence of severe hepatitis C in the liver graft. Elina Teicher M.D.* , Jean-Charles Duclos-Vallée M.D., Ph.D. §, * Internal Medicine Service, Kremlin Bicêtre Hospital, Public Hospital System of Paris, Kremlin Bicêtre, France, Hepatobiliary Center, Paul Brousse Hospital, Public Hospital System of Paris, Villejuif, France, Mixed Research Unit in Health 785, University of Paris-Sud, Villejuif, France, § Unit 785, National Institute of Health, and Medical Research, Villejuif, France.