UK guidelines have been issued for liver transplants in HIV-positive individuals. Approximately 200 HIV-positive patients worldwide have received new livers, demonstrating that individuals responding well to anti-HIV therapy may be good candidates for transplant. However, standard protocols used to determine suitable candidates for transplant and their management need adjustment in the context of HIV and the new UK guidelines provide clinicians with criteria to assess suitable candidates for transplantation and advice on the management of patients who have received a new liver.
The new UK guidelines were developed by the British HIV Association (BHIVA), the UK and Ireland Liver Transplantation Centres, and reviewed and endorsed by the British Transplantation Society Standard Committee. The guidelines were written following a consensus meeting of specialists in the field of HIV and liver transplant in the summer of 2004.
Approximately 5 – 10% of HIV-positive individuals in the UK are coinfected with hepatitis B or hepatitis C virus (or both), and liver-related illness has emerged as a significant cause of illness and death in these individuals since HAART became available. HIV infection was often considered to rule out an individual as a candidate for liver transplant, however this has changed due to the improved prognosis for many HIV-positive individuals since the advent of HAART.
To be considered a suitable candidate for transplantation an individual must satisfy criteria relating to the status of their liver disease; be responding well to HAART, and meet other criteria relating to drug and alcohol use and mental health.
Assessing candidates for liver transplant
Liver transplants should be considered in cases of drug hepatotoxicity resulting in acute liver failure and where appropriate, in patients with hepatitis B virus or/and hepatitis C virus.
Chronic liver disease and cirrhosis are indications for liver disease, including cases of decompensated liver disease, poor liver function (for example albumin below 30g/l, or bilirubin above 50umol/l), or liver cancer. Suitable candidates for transplant should be referred to their regional transplantation centre as soon as possible.
Because of a shortage of donor livers, the guidelines state that to be considered for a transplant, patients must have a prognosis (not related to their liver disease) of at least 50% for five years after receiving a new liver.
To meet this criteria, HIV-positive patients must, in almost all cases, have a CD4 cell count above 200 cells/mm3, have an undetectable viral load, have no active opportunistic infections (except immune reconstitution inflammatory syndrome during the early stages of HAART), and have viable HIV treatment options.
Current injecting drug users, alcoholics who have not abstained from alcohol for at least six months, and individuals with cancer in sites other than their liver are not suitable candidates for a transplant, state the guidelines. In addition, patients with heart or lung disease, long-term kidney problems, and those with malnutrition could be excluded from consideration. Poor motivation and mental health problems should also be considered before an individual is accepted as a candidate.
Management of patients who receive liver transplants
There is potential for calcineurin inhibitors, a class of drugs given to transplant recipients, to interact with antiretroviral drugs, especially protease inhibitors. The guidelines therefore emphasise that an individual’s HAART regimen should not be changed without prior consultation with the transplant centre. Therapeutic drug monitoring of both antiretroviral and post-transplantation immunosuppressive drugs is recommended.
Significant pre- and post-transplantation emotional, psychological and counselling needs are highlighted by the guidelines, which note “preparation and emotional support, together with communication around prognosis, ramifications, future adaptation, [and] quality of life…may need attention.” However, the guidelines go on to emphasise “all studies show a marked improvement in quality of life, especially related to physical function, in HIV-negative patients who are successfully transplanted.”
Database
“Given the rapidly evolving knowledge base in terms of selection of suitable candidates and outcomes it is important to monitor the situation through a nationally coordinated database”, write the guideline authors. This database would have information on patients who are suitable candidates for transplant, time taken before a transplant is performed, and the outcome both for patients who received a new liver and those who did not.
O’Grady J et al. Guidelines for liver transplantation in patients with HIV infection. British HIV Association, UK and Ireland Liver Transplantation Centres, and reviewed and endorsed by the British Transplantation Society Standard Committee, April 2005.