No abstract

We read with interest the article by Vibert et al. 1 recently published in HEPATOLOGY. The authors described their single-center experience with liver transplantation for hepatocellular carcinoma (HCC) in human immunodeficiency virus (HIV)-positive patients (21 cases) and compared those patients to HIV-negative patients (61 cases) who were also affected by HCC. Because of the higher dropout rate among the HIV-positive patients (23.8% versus 11.4%), HIV infection impaired the results of liver transplantation for HCC on an intent-to-treat basis but had no significant impact on overall survival and recurrence-free survival after liver transplantation. In our center from 2005 to 2010, we performed transplantation for 13 HIV-positive patients affected by HCC. The characteristics of this cohort are reported in Table 1. Unlike Vibert et al.'s patients, none of our patients were dropped from the waiting list. None experienced HCC recurrence, although three patients were outside the Milan criteria at listing (23%); only one of those patients (7.7%) had microvascular invasion. Seventy-seven percent had grade 2 and 23% had grade 3 HCC according to The mean number and total diameter of the HCC nodules were 2 6 1 and 46 6 29 mm, respectively, upon pathological analysis. Before transplantation, all patients were treated with transarterial chemoembolization or combined transarterial chemoembolization and radio frequency ablation; the mean necrosis value was 67% 6 39% for the HCC nodules upon pathological analysis. Finally, the 1-, 3-, and 5-year patient and graft survival rates were 84.6%, 84.6%, and 70.5% and 84.6%, 84.6%, and 84.6%, respectively, with a median follow-up of 35 months (range ¼ 2-73 months). In conclusion, our experience seems to be comparable to the experience reported by Vibert et al. except for the absence of HCC recurrence, which was present in 23.8% of the patients investigated in the French cohort.

TO THE EDITORS:We read with interest the article by Terrault et al. 1 recently published in Liver Transplantation. The authors prospectively described a series of human immunodeficiency virus (HIV)-infected patients undergoing liver transplantation (LT) at several US centers, and they reported lower survival rates for patients coinfected with HIV and hepatitis C virus (HCV) versus patients infected with HCV alone. The 3-year patient survival rates were 60% [95% confidence interval (CI) ¼ 47%-71%] for HCV/HIV-coinfected recipients and 79% (95% CI ¼ 72%-84%) for HCVinfected recipients (P < 0.001). HIV infection was the only factor significantly associated with reduced patient and graft survival. Among HCV/HIV-coinfected patients, an older donor age [hazard ratio (HR) ¼ 1.3 per decade], combined kidney-liver transplantation (HR ¼ 3.8), an HCV-positive donor (HR ¼ 2.5), and a body mass index less than 21 kg/m 2 (HR ¼ 3.2) were independent predictors of graft loss. The 3-year incidence of treated acute rejection was 1.6-fold higher for HCV/HIV-coinfected patients versus HCVmonoinfected patients (P ¼ 0.02), but the cumulative rates of severe HCV disease (29% versus 23% at 3 years) were not significantly different (P ¼ 0.21). The authors concluded that HCV per se is not a contraindication for LT in patients with HIV, but the selection of recipients and donors and the management of acute rejection strongly influence outcomes.We would like to comment on the results of Terrault et al. 1 and report the outcomes of 32 consecutive HIVinfected patients undergoing LT at our center in Udine, Italy (2004-2010. This study protocol was approved by the institutional review committee of the Italian National Transplant Center. The characteristics of these patients are shown in Table 1. The listing criteria were (1) no history of acquired immune deficiency syndrome (ie, illness in the previous 2 years), (2) a stable CD4 count > 200 cells/mL in the previous 6 months (or a count > 100 cells/mL if the patient was intolerant of highly active antiretroviral therapy because of hepatic toxicity), and (3) undetectable HIV RNA (in the case of current highly active antiretroviral therapy). Twenty-six patients (81%) were HIV/HCVcoinfected. The patients were followed up for a median of 2.89 years [interquartile range (IQR) ¼ 2.88-4.13 years, range ¼ 0-6.2 years], and there were 7 deaths (21.9%) over a cumulative follow-up time of 86.7 years. The estimated survival rates were 83.1% (95% CI ¼ 79.8%-99.5%) at 3 years and 69.8% (95% CI ¼ 63.7%-92.6%) at 5 years for the entire cohort. The estimated 3-and 5-year survival rates were 78.6% (95% CI ¼ 55.4%-90.6%) and 68.8% (95% CI ¼ 39.6%-85.9%) for HIV/HCV-coinfected patients and 100% (95% CI ¼ not applicable) and 75% (95% CI ¼ 12.8%-96.1%) for HIVmonoinfected patients. According to a univariate Cox regression analysis, only a pre-LT CD4 cell count nadir < 100 cells/mm 3 was a risk factor for death (HR ¼ 5.25, 95% CI ¼ 1.17-23.53, P ¼ 0.03). Biopsy-proven acute rejection was diagnosed in only 2 cases (6....