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