Successful Anti-Retroviral Therapy in an HIV-Infected Man with Short Gut Syndrome and First Multivisceral Transplant.

Abstract

Background: Intestinal transplantation in HIV infection has not previously been reported. We describe our approach to achieving and sustaining virologic control in a HIV positive patient with short gut syndrome (SGS) prior to and 12 weeks after multivisceral transplantation (MVT). Methods: Lopinavir concentrations obtained with IRB approval through HIV TDM registry at the University of Buffalo. Raltegravir concentrations obtained commercially. Results: A 37M diagnosed with HIV at time of mesenteric thrombosis in 4/2011 required near complete enterectomy with 68 cm residual duodenum and upper jejunum. HIV viral load (VL) of 1.5x 106 copies(c)/ml dropped 1 log c/ml immediately after bowel removal. Still in care but treatment naïve with VL 19,700 c/ml and CD4 208 cells/ul (36%), he presented 8/2013 with liver failure for MVT evaluation. On 9/9/2013 lopinavir/ritonavir 800/200 mg liquid PO Q8hr and saquinavir 1 gm Q8hr x 4 days were administered to demonstrate absorption. Lopinavir trough of 7.3 ug/ml (goal >1 ug/ml) was achieved. On 10/10/2013 triple therapy (lopinavir/ritonavir 800/200mg Q12hr + enfuvirtide 90mg SC Q12hr, AZT 300mg IV Q12hr) were initiated. VL <20 c/ml was achieved on 11/6/2013. On 11/7/2013 he underwent MVT (stomach, intestine, liver, pancreas, kidney) without induction immunosuppression. On post-MVT day 7, raltegravir 400mg crushed tablet Q12hr, abacavir liquid 300mg Q12hr and lamivudine liquid 50mg daily (renal dose) were initiated by J-tube. Raltegravir 3-hr and trough were 4.57 (goal 0.79-2.27) and 0.5 (goal 0.03-0.12) ug/ml, respectively. HIV VL remained <20 c/ml and CD4 45-83 cells/ul (27-34%) after MVT. He had 3 documented episodes of intestinal rejection. He remained on prophylactic TMP/SMX, azithromycin, and ganciclovir. He experienced prolonged intra-abdominal infection with highly resistant Citrobacter freundii and died at 12 weeks with widespread gram negative septicemia. Conclusions: HIV viral suppression can be achieved with high dose liquid lopinavir/ritonavir in combination with enfuvirtide and IV zidovudine in the setting of SGS. Successful HIV viral suppression can persist after MVT with a standard regimen of abacavir, lamivudine and raltegravir. We recommend therapeutic drug monitoring in this setting.