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 o f the otherwise poor prognosis. During preparations for it he was found als o 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/m l(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 wer e several complications postoperatively: ischaemic-toxic tubular renal fail ure requiring haemodialysis, underperfusion of the right lobe of the liver due to arterial stenosis, pleural effusion, cytomegalovirus infection and c yclosporin-induced hypertension. But all these were successfully managed. A t the time of this report, 27 months later, the patient felt well and his i mmune 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 functi on. There has been no indication for antiviral treatment and there have bee n no complications relating to immunosuppression. Conclusion: The low life expectancy before effective antiviral drugs are av ailable explains the reluctance to perform OLTX in HIV-infected patients. T he favourable course in this case, using highly efficacious combined antire troviral treatment now being available, indicates that after careful consid eration, OLTX can be performed in selected patients with HIV.