HIV-positive Recipients Research Articles

Liver transplantation in human immunodeficiency virus-infected patients: Procoagulant, but is antithrombotic prophylaxis required?

Liver transplantation (LT) for human immunodeficiency virus (HIV)-positive recipients with end-stage liver disease has become an accepted practice. However, because these patients are increasingly being recognized as prothrombotic, we reviewed their posttransplant thrombotic complications. Because morphological changes might be responsible in part for this prothrombotic state, we also conducted a histopathological review of explants from HIV-positive patients. Between 1990 and 2010, 24 of 3502 recipients (including 23 adults) were HIV-positive at LT. These patients and their postoperative courses were reviewed with a particular focus on vascular complications, risk factors, and outcomes. Another patient in whom HIV was detected 12 years after LT was also examined. Among the 24 HIV-positive LT recipients (17 males and 22 whole liver grafts; median age = 40 years), 5 developed arterial complications [including 3 cases of hepatic artery thrombosis (HAT), 1 case of generalized arteriopathy (on angiography), and 1 case of endoarteritis (on histological analysis)]. Multiple arterial anastomoses were performed in 8 of the 24 recipients, and HAT occurred twice within this anastomosis group. The outcomes of the 3 patients with HAT included retransplantation, biliary stenting for ischemic cholangiopathy followed by retransplantation, and observation only. In addition, 5 separate venous thrombotic events were detected in the 24 recipients during this period. Moreover, the delayed-HIV recipient developed delayed HAT and subsequently ischemic cholangiopathy and was being assessed for retransplantation at the time of this writing. In conclusion, the prothrombotic state associated with combined HIV and liver disease is a cause of morbidity after LT: 8 of the 24 recipients (33%) in this series suffered vascular thrombotic complications. There is a potential increase in the risk of HAT: the rate for the HIV-positive cohort was higher than the rate for historical HIV-negative controls [12% versus 3.2%, P = 0.016 (Fisher's exact test)]. The minimization of complex arterial reconstruction, coagulopathy screening, and risk-adapted antithrombotic chemoprophylaxis appear to be reasonable precautions.

Simultaneous Pancreas Kidney Transplantation in the HIV-Positive Patient

HIV is no longer an absolute contraindication to solid organ transplantation. However, few reports have been published with regards to pancreas or simultaneous pancreas kidney transplantation in the HIV-positive recipient. We report, to our knowledge, the first simultaneous pancreas kidney transplantation (SPK) performed in an HIV-positive patient in the United Kingdom. We reflect on the article recently published by Miro et al in Transplantation Proceedings and highlight strategies used by our department to prevent drug interactions in these complex patients.

Alloantigen-Specific Response Is Preserved and Autoimmunity Is Maintained in an HIV-Positive Patient With Immunoglobulin A Nephropathy Undergoing Renal Transplantation: A Warning About Long-Term Reduction in Immunosuppression—A Case Report

We report the case of a 43-year-old patient with HIV infection treated with antiretroviral therapy, which was complicated by immunoglobulin A (IgA) nephropathy and renal failure, who subsequently was transplanted using a deceased donor kidney transplant. During the late posttransplant period we detected specific anti-donor HLA antibodies showing a preserved alloantigen response. A renal biopsy showed no acute cellular or humoral rejection, an absence of pericapillary C4d deposits or SV40 infected cells, but demonstrated IgA mesangial deposits and mild interstitial fibrosis probably related to calcineurin inhibitor toxicity. This case shows that allo- and autoimmune responses are preserved despite immunosuppressive treatment and original HIV disease. It warns of the importance of maintaining optimal monitoring and immunosuppressive strategies among HIV-positive recipients who become solid organ transplant recipients.

The D&T Report

The D&T Report

Long-Term Outcomes of Orthotopic Liver Transplantation in Human Immunodeficiency Virus–Infected Patients and Comparison With Human Immunodeficiency Virus–Negative Cases

Human immunodeficiency virus (HIV) positivity is no longer a contraindication for orthotopic liver transplantation (OLT) due to the efficacy of antiretroviral therapy. The aim of this study was to compare OLT among HIV-positive and HIV-negative cohorts; the results were also stratified for hepatitis C virus (HCV) coinfection. Between 2004 and 2009, all HIV-infected patients undergoing OLT from heart-beating deceased donors (n = 27) were compared with an HIV-negative cohort (n = 27). The pure HCV infection rate was similar between HIV-positive and HIV-negative subjects (63% each). HIV-positive recipients were younger ( P = .013). The CD4 count for HIV-positive subjects was 376 ± 156 at transplantation. The mean model for end-stage liver disease (MELD) score at transplantation was 15 ± 7 in both groups ( P = .92). No differences were observed for donor age ( P = .72) or time on the waiting list ( P = .56). The median follow-up was 26 (range, 1–64) and 27 months (range, 1–48) for HIV and non-HIV recipients, respectively ( P = .85). The estimated 1-, 3-, and 5-year patient and graft survival rates were 88%, 83%, and 83% versus 100%, 73%, and 73% ( P = .95), and 92%, 87%, and 87% versus 95%, 88%, and 88% ( P = .59) for HIV and non-HIV cases, respectively. HIV/HCV–coinfected patients were younger, namely 47 (range, 40–53) versus 52 years (range, 37–68; P = .003), and displayed lower MELD scores at transplantation compared with HCV–mono-infected patients 10 (range, 7–19) versus 17 (range, 8–30) ( P = .008). For HIV/HCV–coinfected and HCV–mono-infected cases the estimated 1-, 3-, and 5-year patients and graft survival rates were respectively 93%, 76%, and 76% versus 100%, 70%, and 60% ( P = .99) and 93%, 84%, and 84% versus 100%, 70%, and 60% ( P = .64), respectively. No difference was observed in the histological severity of HCV recurrence. In conclusion, under specific, well-determined conditions, OLT can be a safe, efficacious procedure in HIV patients.

9 Incidence of BK Virus Nephropathy in HIV Positive Renal Transplant Patients

INCIDENCE OF BK VIRUS NEPHROPATHY IN HIV POSITIVE RENAL TRANSPLANT PATIENTS Irfan Ahmed, Dwight Matthew, Satyam Arora, Gary Xiao, Gregory Malat, Alden Doyle, Karthik Ranganna BK virus has been associated with kidney dysfunction by causing tubulointerstitial nephritis and ureteral stenosis in kidney transplant recipients. BK virus nephropathy has been reported to be seen in about 1-10% in non HIV kidney transplant recipients. Incidence of BK virus nephropathy in HIV positive recipients of kidney transplants has not been well characterized. To examine the incidence of BK virus nephropathy in HIV renal transplant recipients. We conducted a retrospective chart review on HIV patients who have received kidney transplant at our institution. A total of 92 HIV patients have received kidney transplants at our institution since 2001. All our HIV positive transplant recipients received induction therapy with basiliximab and were given cyclosporine based immunosuppressive regimen. BK virus urine and plasma BK virus PCRs were checked when there was clinical suspicion of BK nephropathy. SV 40 staining was performed on renal biopsies when there were signs of BK nephropathy. Mean age of recipients was 47 ± 8 yrs, 87% were males, 88% were African-Americans, 91% kidneys were from deceased donors out of which 14% were from extended criteria donors. Delayed graft function was seen in 39% of patients. 72% patients had acute rejection during the follow up, out of these 14% had humoral rejection. 32 patients had SV 40 staining performed on their renal biopsies and none of them had positive results. 9 patients had BK virus plasma PCR checked of which 1 patient had positive PCR (32743 copies/mL), same patient had positive in situ DNA hybridization test positive on renal biopsy confirming BK nephropathy. We found an overall incidence of BK nephropathy of 1.08% which is lower than the reported incidence of BK nephropathy in non HIV kidney transplant recipients. This finding in conjunction with high rate of acute rejection (72%) in these patients reflects that these patients received less aggressive immunosuppressive therapy or may have less risk of BK nephropathy.

Kidney Transplantation Outcomes in HIV Infection: The European Experience

Kidney Transplantation Outcomes in HIV Infection: The European Experience

Human embryonic stem cell lines with ccr5-del32 allele conferring resistance to HIV

A 32bp deletion in the chemokine receptor 5 (CCR5) gene (CMKBR5) was shown to be linked to HIV resistance. Bone marrow transplantation from the homozygous CCR5-del32 donor to a CDC Stage 2 HIV-positive recipient was demonstrated to confer a HIV resistance, resulting in discontinuation of antiretroviral therapy. In search for an unlimited source of CCR5-del32 cells for transplantation purposes, we tested 137 human embryonic stem cell (hESC) lines from the Reproductive Genetics Institute’s hESC lines collection, and report here the finding of 12 hESC lines with the CCR5-del32 allele, one of which represents a unique partenogenetic ESC line containing two copies of this deletion and may be studied for utility in stem cell transplantation treatment of HIV.

MTOR Immunosuppression in HIV-Positive Liver Transplant Recipients

We read with interest the article by Di Benedetto et al. (1) regarding their experience with rapamycin as the principal immunosuppressive drug in HIV-positive recipients of liver transplantation. The authors reported switching from calcineurin inhibitors (CNIs) to rapamycin in six patients mainly because of renal dysfunction (five of six) at a median of 67 days (range 10-225 days) from transplantation. The main message from this experience comes, however, from the data regarding HIV-RNA control in patients under rapamycin therapy. The authors reported that cases taking rapamycin had a better control of HIV-RNA replication than cases under CNIs, suggesting a possible antiretroviral effect of rapamycin. However, it is not clear to us why most of the patients taking CNIs have detectable HIV-RNA viral load because they are all actively taking antiretroviral therapy (ART), which was restarted, on average, 16 days after transplant (range 9-58 days) with at least three drugs in association, such as their counterparts on rapamycin treatment. In our personal experience (30 liver transplantations in HIV-infected patients), we were able to suppress HIV-RNA in all cases that were on ART after transplantation. What we would expect is that all cases under ART would have suppressed HIV-RNA viral load independently from the type of immunosuppression. In particular, we switched seven patients from CNIs to mammalian target of rapamycin (mTOR; three to rapamycin and four to everolimus) at a median of 17 months (range 11-22 months) after transplantation for renal impairment attributed to CNIs toxicity. All those cases, which were actively taking ART at the moment of switching from CNIs to mTOR, were already HIV-RNA negative and remained negative while on mTOR treatment. Therefore, on the basis of our experience, we would suggest that control of HIV-RNA viremia in liver transplanted patients is still a matter of the choice of the best ART independently from the type of the antirejection treatment; moreover, the use of rapamycin in this context may be misleading because it has been already clearly demonstrated that ART has an impact on overall survival in HIV-positive liver transplanted patients (2). A possible antiretroviral effect of an mTOR class of immunosuppressant, as hypothesized in the literature (3–5), should be investigated only in patients not taking effective ART for any reason after transplantation. Umberto Baccarani1 Gian Luigi Adani1 Marcello Tavio2 Paolo Grossi3 Pierluigi Viale4 1 Transplantation Unit University of Udine Udine, Italy 2 Division of Infectious Diseases of Ancona Ancona, Italy 3 Institute of Infectious Diseases University of Insubria Varese, Italy 4 Institute of Infectious Diseases University of Bologna Bologna, Italy

Too little, too late: Comparison of nutritional status and quality of life of nutrition care and support recipient and non-recipients among HIV-positive adults in KwaZulu-Natal, South Africa

Compare the nutritional vulnerability, risk of malnutrition, nutritional status and quality of life (QoL) between recipients and non-recipients of nutrition care and support (NCS) of HIV-positive adults. In 2009, a household-based cross-sectional study of HIV-positive adults, NCS recipients (n=97) and non-NCS recipients (n=203) from KwaZulu-Natal was conducted. Nutritional vulnerability (socio-economic status; food security; self-reported health status; nutritional knowledge and attitude), risk of malnutrition (nutrition assessment screening tool), anthropometry (body mass index; mid-upper arm circumference; waist-to-hip ratio) and QoL (general health; self-care; physical functioning) were compared between the two groups. Although the result suggests a modest impairment of QoL, NCS recipients were twice as likely to have severe impairment of general health; self-care functioning and QoL. Overweight and obesity were common despite indications of high prevalence of food insecurity, possible-risk of malnutrition and diets predominantly of cereals. NCS recipients were more frequently taking anti-retroviral drugs, receiving social grants, reporting good eating plans and owning kitchen gardens. Non-NCS recipients had been generally sick, reported fatigue, nausea, appetite loss and diarrhoea. NCS recipients were twice as likely to experience oral thrush. Contextual factors such as low dietary diversity and household food insecurity that exacerbates nutritional vulnerability and malnutrition should be considered when providing NCS to fully achieve nutritional recovery and QoL of HIV-positive adults.

Evaluation of the Architect ® tacrolimus assay in kidney, liver, and heart transplant recipients

The narrow therapeutic range of tacrolimus requires therapeutic drug monitoring to prevent transplant rejection and to minimize nephrotoxicity. The aim of this study was to evaluate the analytical performance of the tacrolimus chemiluminescent microparticle immunoassay (CMIA) in everyday practice comparatively with other methods. CMIA imprecision and accuracy were tested using low, medium, and high concentrations in control samples. The limits of quantification (LOQ) of CMIA and antibody-conjugated magnetic immunoassay (ACMIA) were evaluated using negative whole-blood samples containing 0.4–5.7 ng/ml of tacrolimus from a stock solution. CMIA was compared with ACMIA, enzyme multiplied immunoassay (EMIT), and liquid chromatography–tandem mass spectrometry (LC–MS/MS), using 176 samples from recipients (135 men and 41 women) of heart ( n = 19), kidney ( n = 107), or liver ( n = 50) transplants. CMIA total precision was 5.7%, 3.7% and 3.6% with the low-, medium-, and high-concentration controls, respectively; corresponding values for accuracy were 98%, 104%, and 104%. LOQ was 0.5 (95%CI, 0.22–1.38) with CMIA and 2.5 ng/ml with ACMIA. Linear regression results were as follows: CMIA = 1.2LC–MS/MS + 0.14 ( r = 0.98); CMIA = 0.93EMIT + 0.36 ( r = 0.975); CMIA = 1.15ACMIA − 0.25 ( r = 0.988); and, for tacrolimus concentrations in the 1–15 ng/ml range, of special interest as many transplant recipients are given low-dose tacrolimus, CMIA = 1.05LC–MS/MS + 0.38 ( r = 0.94). Two patients had falsely elevated tacrolimus concentrations due to interference in the ACMIA assay; one was a renal transplant recipient who stopped her treatment and had tacrolimus concentrations of 12.5 ng/ml by ACMIA and <0.5 ng/ml by CMIA; the other was an HIV-positive renal transplant recipient whose tacrolimus concentrations by ACMIA were 1.8–43.7-fold those by CMIA. Such interferences with ACMIA, which may be related to endogenous antibodies in the plasma, are likely to negatively impact patient care. In conclusion, the tacrolimus CMIA assay is suitable for routine laboratory use and does not suffer from the interferences seen with ACMIA in some patients.

Renal Transplantation between HIV-Positive Donors and Recipients

Investigators in South Africa undertook four renal transplantations involving HIV-positive donors and HIV-positive recipients with end-stage renal disease. At 12 months after transplantation, all recipients had good renal function and had not needed dialysis since the procedure.

Kidney transplants in HIV-positive recipients under HAART. A comprehensive review and meta-analysis of 12 series

Kidney transplantation is being introduced gradually for the treatment of end-stage renal disease in patients who are human immunodeficiency virus (HIV) positive. Our aim was to review the outcomes of kidney transplantation in HIV-positive recipients who were being treated with highly active antiretroviral therapy (HAART). Eligible papers were English language manuscripts, published between July 2003 and April 2009 and available through Medline, that described three or more recipients of kidney transplants who were HIV positive and undergoing HAART. The regimens for induction and maintenance therapy, organ rejection, patient survival, CD4 counts, HIV progression, infectious complications and deaths were recorded. The survival at 1 year, organ rejection and infectious complications were evaluated using a random effects model with 95% confidence intervals (CI). Twelve case series met the defined criteria. Induction therapy consisted most commonly of the administration of anti-CD25 monoclonal antibodies, and triple immunosuppressive therapy was used most commonly for maintenance. Among the 254 patients, 1-year survival was 0.93 (95% CI, 0.90-0.96), organ rejection was diagnosed in 0.36 (95% CI, 0.25-0.49) and infectious complications occurred in 0.29 (95% CI, 0.17-0.43). The CD4 counts decreased after transplantation but recovered later. Acquired immune deficiency syndrome (AIDS)-defining infections occurred in three patients. Kidney transplantation appears to be safe in patients undergoing HAART. However, larger series of patients are needed to determine the best protocols for the induction and maintenance of immunosuppression.

Organ transplantation between HIV-infected patients

This article focuses on organ transplantations between HIV-negative donors and HIV-positive recipients and the ethical arguments that have been put forward as to why transplantation in HIV-infected patients should be viewed as analogous to transplantation in patients with other chronic illnesses. It states that provided adequate safety measures can be put in place to safeguard the interests of HIV-infected recipients organ transplantations between competent and consenting HIV-infected individuals should be permitted and such a policy change could save thousands of lives.

HIV-positive kidney transplants for HIV-positive individuals: Attitudes and concerns of South African patients and health care workers

In South Africa, an estimated 30% of the cadaveric donor pool is HIV-infected; in consequence, these organs are discarded. An undersupply of donor organs combined with limited resources, tends to exclude HIV-positive patients from renal replacement programmes. We evaluated the acceptance of using HIV-positive donor kidneys for transplantation into HIV-infected recipients, and found that the vast majority (90% of health care workers and 80% of patients, N=20 and 80, respectively) found this approach acceptable for expanding the organ donor pool, which indicates broad patient and health care worker support for using HIV-infected donor kidneys.Participants: 80 patients were recruited from four different groups: those with HIV on stable antiretroviral (ARV) therapy but with no kidney disease; stable antiretroviral therapy, with kidney disease, including on dialysis; and HIV-uninfected patients, both on dialysis and those with functional kidney transplants. Discussions with 20 health care workers were also conducted. Results: The vast majority (90% of health care workers and 80% of patients, n=20 and 80 respectively) found transplant of HIV-infected organs to HIV-positive recipients an acceptable method for expanding the organ donor pool. This study found no significant difference between the groups of patients regarding whether they approved of using HIV-positive donors; HIV positive patients were willing to accept kidneys from HIV-infected family members, while HIV-negative patients were very unlikely to accept HIV-infected organs. Health care workers expressed concern about initiatives to expand the donor pool and educate patients concerning transplant eligibility. Conclusion: These findings indicate broad patient and health care worker support for the use of HIV-infected donor kidneys for some types of renal patients.

Renal Transplantation in HIV-Positive Recipients

About 1% of all patients with end-stage renal disease in the United States are infected with HIV. With the introduction of highly active antiretroviral therapy (HAART), HIV death rates have declined 80%, and chronic diseases resulting from HIV have replaced opportunistic infections as the leading cause of death among HIV-infected patients. Traditionally, HIV infection has been considered an absolute contraindication to solid-organ transplantation. However, in the context of improved survival, the role for kidney transplantation among HIV-positive patients is currently being revisited. This article discusses long-term outcomes after kidney transplantation in the HAART era and management strategies for the HIV-positive kidney transplant recipient.

The Effect of Intermittent Preventive Treatment during Pregnancy on Malarial Antibodies Depends on HIV Status and Is Not Associated with Poor Delivery Outcomes

Intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended for malaria prevention in sub-Saharan Africa. However, studies reporting the effect of IPTp on malaria-specific immunity are scarce and are based on findings in human immunodeficiency virus (HIV)-negative primigravidae. Plasma samples obtained from 302 pregnant women (177 who were HIV negative, 88 who were HIV positive, and 37 who were of unknown HIV status) participating in a placebo-controlled trial of IPTp with SP (IPTp-SP) were analyzed for the presence of antibodies against merozoite antigens, whole asexual parasites, and variant surface antigens from chondroitin sulfate A-binding and nonbinding lines. Antibody levels were compared between intervention groups, and their association with morbidity outcomes was assessed. HIV-positive mothers receiving SP had lower levels of peripheral antibodies against apical membrane antigen-1 and variant surface antigens, as well as lower levels of cord antibodies against erythrocyte-binding antigen-175 and parasite lysate, than did HIV-positive placebo recipients. No difference between intervention groups was observed among HIV-negative mothers. High antibody levels were associated with maternal infection and an increased risk of a first malaria episode in infants. Antibody responses were not consistently associated with reduced maternal anemia, prematurity, or low birth weight. The IPTp-associated reduction in antibodies in HIV-infected women, but not in HIV-uninfected women, may reflect a higher efficacy of the intervention in preventing malaria among HIV-positive mothers. This reduction did not translate into an enhanced risk of malaria-associated morbidity in mothers and infants. Trial registration. Clinicaltrials.gov identifier NCT00209781.

P01-271 - Evaluation of HIV positive recipients of orthotopic liver transplant (OLT): an observational study in the modena consultation liaison psychiatric service

ObjectivesTo evaluate psychiatric features in liver post transplant HIV recipients.MethodsAn observational study was conducted. Different psychiatric rating scales to evaluate cognitive status (MMSE), anxiety and depressive symptoms (HAM-A, HAM-D), social phobia (BSPS), quality of life (SF-36), sexual satisfaction (ISS), coping strategies (Brief Cope) and alcohol-drug abuse (LDQ) were submitted to a population of 11 HIV outpatients that underwent to OLT (19% of the Italian HIV transplant recipients). Scores were statistically related to socio-demographic and clinical data.ResultsAll patients were male, aged between 33 and 54 years. In the past 8 patients were drug abusers, three suffered from depression. At the moment of the evaluation 8 patients didn't suffer from any psychiatric disease while the three youngest patients presented a mild depressive status. BASIS-32 scores were related to HAM-D and to a history of drug abuse (p&lt; 0.01). SF-36 was related to age (p&lt; 0.05), HAM-D (p&lt; 0.01), BSPS and BASIS 32 (p&lt; 0.02).ConclusionsDespite the higher risk for a HIV patient of developing an anxious or mood disorder, our population isn’t affected by psychiatric diseases; this is an encouraging data considering that post transplant period can be very stressful. This result may be due to a personality organization or a coping style strengthened by a long term disease such as HIV. Further studies are needed to investigate psychosocial outcome of OLT in HIV and to improve our knowledge of this controversial issue and guarantee a better take in care of these complex patients.

Viable strategies to facilitate liver transplantation for human immunodeficiency virus coinfection

The morbidity and mortality associated with human immunodeficiency virus (HIV) have dramatically decreased as a result of highly active antiretroviral therapy (HAART). Although people infected with HIV are no longer dying from the progression of HIV to acquired immune deficiency syndrome, end-stage liver disease secondary to the viral copathogens hepatitis B virus (HBV) and hepatitis C virus (HCV) has become a major cause of mortality in developed countries. As infection with HIV has evolved into a chronic disease, an increasing number of coinfected people are being referred for liver transplantation in the United States and Europe. Although many transplant centers still consider HIV infection a relative contraindication to transplantation, those with early experience in coinfected recipients with well-controlled HIV have reported excellent results following liver transplantation for hepatitis B and poorer but acceptable results following liver transplantation for hepatitis C. At the same time, transplant centers that have been proceeding with liver transplantation in coinfected patients have reported significantly shorter pretransplantation survival in HIV-positive recipients listed for liver transplantation in comparison with HIVnegative subjects. With this background, Murillas et al. in this issue of Liver Transplantation report on the natural history and prognostic factors of end-stage liver disease in HIV-coinfected patients following their first clinical decompensation of liver disease. The findings from this prospective study by Murillas et al. are highly relevant and noteworthy, in that only 14% (15/104) of the coinfected patients in the Spanish cohort experiencing their first documented liver decompensation met the acceptance criteria for liver transplantation and were placed on a waiting list. Furthermore, only 33% (5/15) of the listed patients underwent liver transplantation, and the other 10 (67%) died while on the waiting list for a median survival time of 5 months. It is of equal importance that the Model for End-Stage Liver Disease (MELD) score and the inability to achieve an undetectable plasma HIV-1 RNA load were independent risk factors for death. For those patients listed for liver transplantation, the calculated mortality rate for a given MELD score in HIV-infected patients was similar to the mortality rate in non–HIVinfected patients with a MELD score that was roughly 10 points higher. Although the MELD score correlated with death on the waiting list for the HIV-infected patients, the absolute value of the MELD score was associated with poorer survival rates in comparison with HIV-negative monoinfected patients. The dismal rates of listing (14%) HIV-coinfected patients for transplant, as well as the extremely high death rates on the waiting list, are important observations in this prospective study and deserve further discussion. A significant discrepancy between the US trials and this prospective Spanish trial is related to the inclusion trial for transplantation. Murillas et al. report that a previous history of opportunistic infection (with the exception of tuberculosis) was an exclusion criterion for activation on the waiting list. This exclusion criterion was the reason that a very high percentage of patients (55/89) were precluded from the transplant list. Some

Liver transplantation: an update 2009

In this review we focus on three challenging aspects of liver transplantation: living donor liver transplant, transplantation in HIV-positive recipients and down-staging of hepatocellular carcinoma for liver transplantation. The adult-to-adult living donor liver transplantation cohort study is providing valuable information on recipient and donor outcomes associated with living donor liver transplantation. The recipient outcomes with living donor liver transplantation are comparable to those with deceased donor liver transplantation for most diseases, but increased hepatocellular carcinoma recurrence has been reported with living donor liver transplantation. Donor morbidity is not infrequent and donor mortality remains a concern. Liver transplantation for HIV-positive recipients is associated with equivalent outcomes as HIV-negative recipients for selected recipients. Transplantation in coinfected recipients (HIV and HCV+) is associated with less favorable outcomes. Drug interaction between immunosuppression and highly active antiretroviral therapy is increasingly recognized and requires major modifications in dosing. Down-staging hepatocellular carcinoma to within transplant criteria is being used in some centers using loco-regional therapy. Waiting time after loco-regional therapy is currently the best predictor of recurrence. The role of newer chemotherapeutics is being tested as part of neoadjuvant therapy after resection or loco-regional therapy. Living donor liver transplantation is a viable strategy to increase transplantation and reduce death on the waiting list. Donor morbidity should be the subject of further efforts to minimize these risks. The increased recurrence risk with living donor liver transplantation for hepatocellular carcinoma warrants further study. Careful coordination between transplant professionals and HIV experts is necessary to monitor issues of posttransplant care of the HIV-infected recipient. The role of loco-regional therapies in down-staging patients with hepatocellular carcinoma is expanding.