Specific Problems in a HIV Positive Patient with End-Stage Alcoholic Liver Dis-ease after Liver Transplantation: Infections and Immunosuppression

We report a 54-year-old man with decompensated alcoholic liver cirrhosis and HIV infection who underwent liver transplantation (LTx). Due to relatively well preserved cellular immunity until 2003, no antiretroviral therapy (HAART) needed to be instituted. However, deterioration of his clinical state indicated the need for LTx. At that time, the viral load was of 4.84 Log and the CD4 count was more than 250 cells/mm3. The post transplant course was complicated by several infection episodes and one episode of acute cellular rejection grade 2. HAART consisted of lamivudine, stavudine, lopinavir and ritonavir. One week after start of HAART, TAC were discontinued during 18 days due to ritonavir interaction and successively modified switching ritonavir to nevirapine. CD3/CD4 T-helper lymphocyte count showed a significant decrease immediately after LTx which rapidly recovered after initiation of HAART. The patient was discharged on the 8th post-operative week in good conditions and he is doing very well 1-year following LTx. This report encourages the institution of HAART once the liver graft regains normal function. Drug interactions between ritonavir and tacrolimus should be anticipated. A study protocol to manage these patients within a multidisciplinary team including also specialists in infectious diseases and virologists is mandatory.