Successful Pregnancy after Orthotopic Liver Transplantation in a Patient with HIV Infection
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《新英格兰医药杂志》
To the Editor: An increasing number of patients with HIV infection and viral cirrhosis are receiving liver transplants; among such patients, short-term survival is similar to that among patients undergoing transplantation who do not have HIV infection.1 Within one year after successful liver transplantation, 97 percent of female patients of childbearing age recover menstrual function, owing to restored hepatic estrogen metabolism, and the likelihood of conception and successful pregnancy is high.2 We report a case of a successful pregnancy in an HIV-positive patient who conceived after undergoing liver transplantation.
A 37-year-old woman underwent orthotopic liver transplantation in March 2003, because of infection with hepatitis C virus (HCV) and hepatitis B virus (HBV) and Deltavirus-related decompensated cirrhosis. Immediately after transplantation, immunosuppressive therapy was started with tacrolimus and prednisone, along with antiretroviral therapy with stavudine, lamivudine, and tenofovir, and she received monthly intramuscular injections of anti-HBV immune globulin (at a dose of 1000 IU). During follow-up, HIV RNA was undetectable; the patient was negative for HCV on testing with the polymerase chain reaction (PCR). PCR testing for HBV DNA and immunoassay with the use of microparticles (AxSYM, revision 2, Abbott Laboratories) for HBV surface antigen (HBsAg) were also negative, and the levels of CD4 cells were above 200 per cubic millimeter. Seroconversion to anti-HB Ag–positive status was noted in December 2003. Corticosteroid therapy was stopped in January 2004. In December 2004, the patient reported that she was eight weeks pregnant. Tacrolimus was replaced with cyclosporine, and she was maintained on antiretroviral drugs. After an uneventful 37-week pregnancy, she underwent a scheduled cesarean section while receiving intravenous zidovudine. A baby boy weighing 3020 g was delivered and completed a successful six-week regimen of prophylactic oral zidovudine.
Among HIV-infected-patients, the chief problems after liver transplantation are pharmacokinetic and pharmacodynamic interactions between antiretroviral and immunosuppressive agents, graft rejection, and recurrence of viral hepatitis.1 In our patient, the use of a triple combination of nucleoside analogues appeared to be safe and was adequate to control HIV replication. Moreover, the simultaneous use of tenofovir, lamivudine, and immune globulin appeared to prevent a recurrence of HBV and probably produced the seroconversion to anti-HBs Ag. Although the use of three nucleoside analogues is not recommended for the treatment of HIV infection because of low antiviral potency,3 these combinations offer the advantage of minimal interactions with immunosuppressive agents, and their usefulness in recipients of liver transplants who are infected with HIV has already been suggested.1 Lamivudine is one of the preferred drugs for the treatment of pregnant women with HIV3 and was successfully used during pregnancy in a patient who acquired HBV two years after receiving a liver graft.4
Preterm delivery and low birth weight are common among infants born to mothers who have received solid-organ transplants, irrespective of the type of immunosuppressive therapy used.5 In our patient, the course of gestation was uneventful despite the use of tacrolimus and cyclosporine, and the infant was well and HIV-negative at the age of six weeks. Tests for HCV RNA before transplantation were negative, and the results remained negative after the procedure.
In summary, HIV infection did not result in a more complicated course of pregnancy after liver transplantation, as compared with pregnant transplant recipients who do not have HIV infection, probably owing to adequate management of both HIV and immunosuppression.
Ana Moreno, M.D., Ph.D.
Carmen Quereda, M.D.
Rafael Bárcena, M.D., Ph.D.
Hospital Ramón y Cajal
28034 Madrid, Spain
amoreno.hrc@salud.madrid.org
for the Ramón y Cajal–La Paz Liver Transplant Group
References
Moreno S, Fortún J, Quereda C, et al. Liver transplantation in HIV-infected recipients. Liver Transpl 2005;11:76-81.
Nagy S, Bush MC, Berkowitz R, Fishbein T, Gomez-Lobo V. Pregnancy outcome in liver transplant recipients. Obstet Gynecol 2003;102:121-128.
DHHS guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Rockville, Md.: AIDSinfo, April 7, 2005. (Accessed November 15, 2005, at http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL04072005001.pdf.)
Loreno M, Bo P, Senzolo M, Cillo U, Naoumov N, Burra P. Successful pregnancy in a liver transplant recipient treated with lamivudine for de novo hepatitis B in the graft. Transpl Int 2005;17:730-734.
Jain AB, Reyes J, Marcos A, et al. Pregnancy after liver transplantation with tacrolimus immunosuppression: a single center's experience update at 13 years. Transplantation 2003;76:827-832.
A 37-year-old woman underwent orthotopic liver transplantation in March 2003, because of infection with hepatitis C virus (HCV) and hepatitis B virus (HBV) and Deltavirus-related decompensated cirrhosis. Immediately after transplantation, immunosuppressive therapy was started with tacrolimus and prednisone, along with antiretroviral therapy with stavudine, lamivudine, and tenofovir, and she received monthly intramuscular injections of anti-HBV immune globulin (at a dose of 1000 IU). During follow-up, HIV RNA was undetectable; the patient was negative for HCV on testing with the polymerase chain reaction (PCR). PCR testing for HBV DNA and immunoassay with the use of microparticles (AxSYM, revision 2, Abbott Laboratories) for HBV surface antigen (HBsAg) were also negative, and the levels of CD4 cells were above 200 per cubic millimeter. Seroconversion to anti-HB Ag–positive status was noted in December 2003. Corticosteroid therapy was stopped in January 2004. In December 2004, the patient reported that she was eight weeks pregnant. Tacrolimus was replaced with cyclosporine, and she was maintained on antiretroviral drugs. After an uneventful 37-week pregnancy, she underwent a scheduled cesarean section while receiving intravenous zidovudine. A baby boy weighing 3020 g was delivered and completed a successful six-week regimen of prophylactic oral zidovudine.
Among HIV-infected-patients, the chief problems after liver transplantation are pharmacokinetic and pharmacodynamic interactions between antiretroviral and immunosuppressive agents, graft rejection, and recurrence of viral hepatitis.1 In our patient, the use of a triple combination of nucleoside analogues appeared to be safe and was adequate to control HIV replication. Moreover, the simultaneous use of tenofovir, lamivudine, and immune globulin appeared to prevent a recurrence of HBV and probably produced the seroconversion to anti-HBs Ag. Although the use of three nucleoside analogues is not recommended for the treatment of HIV infection because of low antiviral potency,3 these combinations offer the advantage of minimal interactions with immunosuppressive agents, and their usefulness in recipients of liver transplants who are infected with HIV has already been suggested.1 Lamivudine is one of the preferred drugs for the treatment of pregnant women with HIV3 and was successfully used during pregnancy in a patient who acquired HBV two years after receiving a liver graft.4
Preterm delivery and low birth weight are common among infants born to mothers who have received solid-organ transplants, irrespective of the type of immunosuppressive therapy used.5 In our patient, the course of gestation was uneventful despite the use of tacrolimus and cyclosporine, and the infant was well and HIV-negative at the age of six weeks. Tests for HCV RNA before transplantation were negative, and the results remained negative after the procedure.
In summary, HIV infection did not result in a more complicated course of pregnancy after liver transplantation, as compared with pregnant transplant recipients who do not have HIV infection, probably owing to adequate management of both HIV and immunosuppression.
Ana Moreno, M.D., Ph.D.
Carmen Quereda, M.D.
Rafael Bárcena, M.D., Ph.D.
Hospital Ramón y Cajal
28034 Madrid, Spain
amoreno.hrc@salud.madrid.org
for the Ramón y Cajal–La Paz Liver Transplant Group
References
Moreno S, Fortún J, Quereda C, et al. Liver transplantation in HIV-infected recipients. Liver Transpl 2005;11:76-81.
Nagy S, Bush MC, Berkowitz R, Fishbein T, Gomez-Lobo V. Pregnancy outcome in liver transplant recipients. Obstet Gynecol 2003;102:121-128.
DHHS guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Rockville, Md.: AIDSinfo, April 7, 2005. (Accessed November 15, 2005, at http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL04072005001.pdf.)
Loreno M, Bo P, Senzolo M, Cillo U, Naoumov N, Burra P. Successful pregnancy in a liver transplant recipient treated with lamivudine for de novo hepatitis B in the graft. Transpl Int 2005;17:730-734.
Jain AB, Reyes J, Marcos A, et al. Pregnancy after liver transplantation with tacrolimus immunosuppression: a single center's experience update at 13 years. Transplantation 2003;76:827-832.