Orthotopic liver transplantation in a 33-year-old man with fulminant hepatitis B and HIV infection

History and clinical findings: A 33-year-old man with fulminant hepatitis B infection was to have an orthotopic liver transplantation (OLTX) because of the otherwise poor prognosis. During preparations for it he was found also to have an HIV-infection. Investigations: Preoperatively the Quick value was 9%, and he had a grade 2 encephalopathy. His immune status was impaired: 477 CD4-T-helper cells/mu l. Virus load, measured with a quantitative HIV-RNA test, was < 80 copies/ml(i.e. below demonstrable level). Diagnosis, treatment and course: After the first transplantation had ended in organ failure, a second one two days later was successful. But there were several complications postoperatively: ischaemic-toxic tubular renal failure requiring haemodialysis, underperfusion of the right lobe of the liver due to arterial stenosis, pleural effusion, cytomegalovirus infection and cyclosporin-induced hypertension. But all these were successfully managed. At the time of this report, 27 months later, the patient felt well and his immune state was stable. During these Z years he had a practically normal T-helper count and HIV-RNA measured below 80 copies/ml with good liver function. There has been no indication for antiviral treatment and there have been no complications relating to immunosuppression. Conclusion: The low life expectancy before effective antiviral drugs are available explains the reluctance to perform OLTX in HIV-infected patients. The favourable course in this case, using highly efficacious combined antiretroviral treatment now being available, indicates that after careful consideration, OLTX can be performed in selected patients with HIV.