September 18, 2012
A 32-year-old man received a transplant due to severe hepatitis-C-virus-related liver damage. Doctors noted that he was overweight and a smoker. His immunosuppressive therapy included rapamycin (later changed to cyclosporine) and prednisone (for a total dose of 1,880 mg). His anti-HIV regimen was as follows:
Four months after transplantation the man sought care because of intense left hip pain. MRI and other scans revealed that both of his hips had osteonecrosis. So far he has had his left hip replaced.
The Modena team reported that between 2007 and 2009 (the dates for which figures were made available) 24 HIV-positive people had a liver transplant and three (13%) developed osteonecrosis. In contrast, during the same time period and in the same medical centre, less than 1% of 438 HIV-negative people developed the same problem. This difference is striking and the reasons for it are not clear. Another noteworthy feature of the Modena report is that two of the three HIV-positive patients were relatively young -- under 40 years old.
Due to the small number of HIV-positive people with this complication, robust conclusions about possible effects of specific anti-HIV or transplant drugs and their potential relation to osteonecrosis in these patients cannot be drawn.
As organ transplants for HIV-positive people are becoming more widespread, at least in high-income countries, other transplant centres need to review their databases to see if a similar excess of osteonecrosis among transplant recipients has occurred. If this is confirmed, a large study needs to be done to investigate possible causes of osteonecrosis in HIV-positive people who receive organ transplants.
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