LAUSR

To the Editor: Although the recently reported outcomes of human immunodeficiency virus (HIV)-positive to HIV-positive liver transplantation (LT) performed in the UK and Switzerland are certainly promising, several challenges remain before this transplant option can be expanded. The main risks of this procedure include: HIV superinfection, transmission of drug resistance and/or donor-related infections, drug-related liver dysfunction, and an increased risk of rejection. For the first time in Italy, an HIV-positive man received successful LT for multifocal hepatocellular carcinoma (HCC) on a background of viral cirrhosis from an HIV-positive brain-dead donor in May 2017. The 50-year-old recipient with a 32-year history of infection secondary to injection drug use had refused to take antiretroviral therapy (ART) for almost 20 years of asymptomatic infection. After esophageal candidosis (CDC stage C3) in 2005, a regimen with efavirenz plus tenofovir/emtricitabine was started with clinical and immunological improvement. ART was switched in 2015 to rilpivirine and in July 2016 to dolutegravir, maintaining tenofovir/emtricitabine. Due to the long duration of infection and persistently undetectable HIV-RNA in the previous decade, HIV genotypic resistance testing did not show significant resistance to any drug class before LT. He was negative for HLAB⁄5701, while the virus strain was CCR5 tropic. Advanced liver disease was secondary to hepatitis B virus, hepatitis delta virus co-infection and previous hepatitis C virus infection. In 2016, five years after successful locoregional treatment of the HCC, two new untreatable nodules (within Milan criteria) were diagnosed and the patient was admitted to the waiting list for LT. The patient’s clinical history, and management of HIV infection over time are reported in the table with details of the other two HIV-to-HIV LT reported in the literature (see Table 1). The donor was a 52-year-old HIV-positive man who died from stroke. He was under his first ART regimen (abacavir/lamivudine and dolutegravir) with no history of treatment failure. At the time of organ donation his CD4 cell count was 501 cells/ mm (23%) and plasma HIV-RNA was detectable, with 198 copies/ml, probably resulting from ART suspension due to his severe clinical condition. HIV genotypic resistance test was available four days after liver procurement and no resistanceassociated mutations were reported for nucleosidic and nonnucleosidic reverse transcriptase inhibitors, protease inhibitors or integrase inhibitors. The graft rapidly recovered function after transplant, and no surgical or medical complication occurred. HIV-positive transplant recipients are known to have a higher rejection rate than negative subjects. The recipient received an immunosuppressive regimen associating basiliximab induction, low-dose steroids and tacrolimus. ART with the previous regimen of tenofovir/emtricitabine and dolutegravir was resumed on