People living with HIV have high survival rates after liver transplants due to HCC

People with HIV – most of whom had hepatitis B or C co-infection – generally had good outcomes after liver transplantation due to hepatocellular carcinoma (HCC), with five-year survival rates similar to those of HIV-negative transplant recipients and better than those of people who underwent other types of liver cancer treatment, researchers reported this week at the American Association for the Study of Liver Diseases (AASLD) Liver Meeting in Boston, USA.

People living with HIV often have hepatitis B virus (HBV) or hepatitis C virus (HCV) co-infection and tend to experience more rapid liver disease progression. Traditionally, people living with HIV were not considered good candidates for liver transplants due to concern that immunosuppressant drugs used to prevent organ rejection might worsen HIV-related immune suppression and interact with antiretroviral medications. With improvements in antiretroviral therapy and a move to earlier treatment, however, many people with HIV are in overall good health with well-preserved immune function.

Heather Platt from Columbia University Medical Center and colleagues performed a retrospective analysis of orthotopic liver transplantation among people living with HIV who had HCC, a type of liver cancer that can occur in people with chronic viral hepatitis, especially those who progress to cirrhosis.

The researchers identified 367 people with HIV treated for HCC at 43 centres in North and South America, Europe and Australia between 1995 and 2004. Among these, 27 received liver transplants and 108 underwent other types of potentially curative therapy including surgical resection or tumour removal (51 people), radiofrequency ablation (45 people) and percutaneous ethanol injection (12 people).

Patients who received transplants were slightly younger and had more advanced liver dysfunction with higher Child-Turcotte-Pugh scores than those receiving other types of treatment. However, their causes of liver disease were similar, most commonly HCV infection (78%) or HBV infection (21%). Patients in the different treatment groups had similar liver cancer staging (around 70% with BCLC stages A or B), but transplant recipients more often had multiple liver tumours.

Across treatments, most people had well-controlled HIV disease with more than 80% having undetectable HIV RNA. Median CD4 cell counts were approximately 300 cells/mm³ for transplant recipients and 400 cells/mm³ for those receiving other treatments.

The five-year survival rate was significantly higher for people who received liver transplants (85%) compared to those undergoing other types of treatment (52% combined). The five-year survival rate continued to be higher for transplant recipients compared to other treatments when the analysis was restricted to people with BCLC stage A.

Among transplant recipients, five-year survival was higher for people with early (BCLC stage A and B) compared with late (BCLC stage C and D) liver cancer, 89% vs 67%, respectively.

"For HIV-infected patients with HCC, orthotopic liver transplantation is a therapeutic option with high survival rates which are superior to radiofrequency ablation and surgical resection," the researchers concluded.

They added that the five-year survival rate of 85% "compares favourably" to reported survival rates of 75% to 80% for HIV-negative people with HCC undergoing liver transplants.

"The primary point of this study is to show that HIV-positive patients with HCC should be included in evaluation for orthotopic liver transplantation, as there does not seem to be any difference in survival when compared to HIV-negative patients," Heather Platt stated in an AASLD press release. "Importantly, the survival data, while retrospective, does indicate a benefit compared to other curative interventions."

Addressing barriers to transplantation for people living with HIV, Platt added that the main barriers include a centre's experience and comfort with doing transplants for people with HIV. "HIV-positive patients are examined quite carefully for compliance and for anticipation of post-transplant complications," she said. "This requires a comprehensive, multidisciplinary transplant program including specialists in HIV care."

Speaking at the Liver Meeting's opening press conference, AASLD president Adrian Di Bisceglie – who selected this study as one of a dozen conference highlights – indicated that the improvement in transplant outcomes for people with HIV is likely attributable to better understanding of which HIV-positive patients are good candidates, namely those who are not already highly immunosuppressed.