P1668SIMULTANEOUS LIVER-KIDNEY TRANSPLANTATION IN PEOPLE LIVING WITH HIV: A CASE-SERIES WITH LONG TERM FOLLOW-UP
Authors: Dolci Giovanni , Guaraldi Giovanni , Erica Franceschi , Alfano Gaetano , Fontana Francesco , Di Benedetto Fabrizio , Cappelli Gianni 
Published: June 2020

Abstract

Background and Aims
The number of simultaneous liver-kidney transplants (SLKT) has been constantly increasing in the past two decades. In the US, the relative proportion of liver transplants performed as part of SLKT augmented from 2.7% in 2000 to 9.3% in 2016. In this rapidly evolving scenario, people living with HIV (PLWH) have been substantially excluded from SLKT. The poor prognosis of SLKT in people living with HIV (PLWH) has refrained transplant centers to perform this procedure.

Method
We retrospectively describe indications, clinical characteristics and survival of HIV-infected patients who underwent SLKT at the Transplant Centre of Modena, Italy.

Results
Since 2001 five SLKTs were performed in HIV-affected subjects. With regards to medical eligibility criteria for SLKT all the patients were on hemodialysis and had liver end-stage disease or HCC at time of transplantation (Table 1A). Mean age at transplantation was 47.8± 5.93 years and all patients were Caucasian males. Mean duration of HIV was 25 years and all patients had undetectable HIV-viral load at SLKT. The causes of end-stage renal disease were different in all recipients and only one had biopsy-proven kidney disease. Dialysis vintage was 15.8±10.2 months. Four patients had HCV-related cirrhosis and one had hepato-carcinoma (HCC).
Mean HCV-RNA at SOT was 464,327 copies/ml; in three HCV patients, the sustained virologic response to HCV therapy was obtained after transplant with peg-INF in one case (pre-direct antiviral agent era) and with a combination of sofosbuvir, daclatasvir and rifampicin in the other two. Only one patient had HBV-HDV-related cirrhosis and did not experience HBV or HDV relapse during the follow-up.
At the end of a mean follow up of 7.6±4.71 years, four out of five patients are still alive One patient died on post-transplant day 41 for disseminated candidiasis with cerebral involvement (Table1 b). During the follow-up period, HIV-VL remained undetectable over nearly 10 years. Clinical outcome was characterized by the reverse of frailty in all the patients. All of them are conducting an independent living with quality of life exceeding 90% using the EUQoL 5D-5L questionnaire. The liver function was normal and remained stable during theobservation period. Bile duct stricture and bile duct calculi were the main surgical complications.
Regarding renal function, mean serum creatinine was 1.7±0.4mg/dl corresponding to a mean estimated GFR of 47.7±5.9 ml/min. Only one patient had proteinuria (0.8 gr/daily) after 10 years of transplantation. Contrary to our expectations, no cases of graft rejections occurred during this long-term follow-up despite mean HLA mismatches of 5.75 and underexposure to the immunosuppressive agents. Withdrawn of steroids occurred after 1.8±2.5 years from SLKT. Thereafter, immunosuppressive therapy continued with monotherapy: calcineurin inhibitor in three recipients and inhibitors of the mammalian target of rapamycin in the other one.

Conclusion
Contrary to the previously published data, this case series describes a favorable clinical outcome in PLWH who received SLKT. The absence of graft rejection despite the reduced immunosuppressive therapy highlights the concept that the liver is able to induce tolerance in kidney transplantation. These results could lead other transplant programs to consider SLKT as a reliable clinical option in PLWH with liver and kidney failure.