Liver Transplantation in HIV-Seropositive Individuals

IN RESPONSE:

We thank Dr. Ragni and colleagues for clarifying the prospective nature of their study (1). This was not apparent to us from their Methods section, which stated that “24 subjects with HIV infection and [end-stage liver disease] who fulfilled standard listing criteria for liver transplantation underwent [orthotopic liver transplantation] at 5 institutions.”

Dr. Ragni and colleagues state that there were no differences between the MELD scores of their patients and those of the patients who were HIV-seronegative. However, in the accompanying editorial (2), Dr. Fishman cited a 2002 report by the United Network for Organ Sharing that indicated that the median MELD score during the past year in patients without acute hepatic failure was 22.16. Dr. Fishman also noted that, in regions with severe organ shortages, transplantation could not occur until the MELD score was in the range of 25 to 35.

Dr. Ragni and associates concluded that the survival of HIV-seropositive liver transplant recipients does not differ from that of HIV-seronegative ones. However, the length of follow-up in their 24 recipients was limited; only 3 were followed for at least 36 months. The 5-year survival rate was only 36%, compared with 71% in the HIV-seronegative cohort. Even if this difference was not statistically significant, the numbers are small and the arithmetic difference is large. Failure to prove a difference does not necessarily guarantee the presence of equivalence.

For us, the point of disagreement relates to applicability of the findings in the world of transplantation. As a society, we will have to make decisions regarding resource utilization for health care because those resources (money and organs) are not unlimited. If we cannot use cost and efficacy, what are we to use? Even if we accept the figure of $50 000 per life-year saved (and that figure, if applied to the entire population, is higher than the gross domestic product), organ transplantation in anybody is arguably too expensive. If 2 otherwise similar patients (differing only in HIV status) are competing for 1 available organ, and even if the long-term outcomes are the same, the additional cost of the HIV therapy will add more expense to the post-transplantation care (the authors' data certainly cannot be interpreted to infer that the post-transplantation course of the HIV-seropositive individual is better). If health care resources were infinite, the only issue would be to avoid harm. Because resources are limited, we have to be prepared to make judgments about where to do good.