• cirrhosis
• frailty
• hiv
• liver
• transplant

Background:
The advent of highly active antiretroviral therapy (HAART) radically changed HIV epidemic scenario. Mainly because of the reduction of AIDS defining events and subsequent AIDS-related mortality, HIV-positive patients mortality has dropped during the last two decades. In many settings HIV-infection has been transformed into a mostly manageable chronic disease. With the reduction in AIDS-defining conditions and the rise of life expectancy, age-related diseases are becoming more prevalent in the elderly HIV-positive population.
The epidemiological overlap between HIV and age-associated conditions generated the concept of HIV-associated non-AIDS (HANA) conditions. Chronic HIV-infection is a multisystem illness and can be considered a model of accelerated or accentuated aging. Thus the concept of frailty, original of geriatric medicine, may be useful in an HIV-medicine setting.
ESLD is currently the most frequent non-AIDS-related cause of death in HIV-positive patients. HIV-positive patients presents an higher risk of developing liver disease and cirrhosis, mainly because of the overlapping of risk factors between HIV and viral hepatitis transmission, as well as alcohol-related cirrhosis. In addition, HIV-infection per se increases the risk of Non Alcoholic Fatty Liver Disease (NAFLD) and antiretroviral drugs may cause liver failure. In HAART era HIV-infection is no longer considered a contraindication to Solid Organ Transplant (SOT) and in some cases liver transplant is the only possible therapy.

Objectives: We sought to construct a frailty index based on health deficit accumulation in HIV-positive patients that underwent liver transplantion at Liver and Multivisceral Transplant Center of University of Modena and Reggio Emilia and evaluate its validity including the ability to predict mortality, incident multimorbidity, early re-hospitalization, graft rejection and immunologic gain.
Design and methods: This is an analysis of data from HIV-positive patients that underwent cadaveric donor liver transplantation at the Liver and Multivisceral Transplant Center of University of Modena and Reggio Emilia from June 2003 to June 2015. Thirty variables commonly collected in this setting were included in a Frailty Index (FI). Content, construct, and criterion validity of the FI were assessed. Multivariable regression models were built to investigate the ability of the FI to predict mortality, incident multimorbidity (at least three chronic disease diagnoses) early re-hospitalization, graft rejection and immunologic gain.
Results: Fourty-seven HIV-positive patients underwent liver transplantation at from June 2003 to June 2015. Among them, 5 underwent combined transplant of liver and kidney. Median age at transplant was 51,2 years (IQR 45,91-54,35) and the most common indication for liver transplant was HCV-induced cirrhosis (82,9%), followed by hepatocellular carcinoma (HCC; 44,6%).
Positive pre-transplant HCV-RNA predicted post-transplant mortality. Positive pre-transplant HCV-RNA and FI were associated, even if not statistically significantly (p=0.12), with early re-hospitalization.
Locally Weighted Scatterplot Smoothing (LOWESS) showed a FI reduction in HIV-transplanted patients population after liver transplant. This decrement was more evident in surviving patients vs patients that would eventually die.

Background: The advent of highly active antiretroviral therapy (HAART) radically changed HIV epidemic scenario. Mainly because of the reduction of AIDS defining events and subsequent AIDS-related mortality, HIV-positive patients mortality has dropped during the last two decades. In many settings HIV-infection has been transformed into a mostly manageable chronic disease. With the reduction in AIDS-defining conditions and the rise of life expectancy, age-related diseases are becoming more prevalent in the elderly HIV-positive population. The epidemiological overlap between HIV and age-associated conditions generated the concept of HIV-associated non-AIDS (HANA) conditions. Chronic HIV-infection is a multisystem illness and can be considered a model of accelerated or accentuated aging. Thus the concept of frailty, original of geriatric medicine, may be useful in an HIV-medicine setting. ESLD is currently the most frequent non-AIDS-related cause of death in HIV-positive patients. HIV-positive patients presents an higher risk of developing liver disease and cirrhosis, mainly because of the overlapping of risk factors between HIV and viral hepatitis transmission, as well as alcohol-related cirrhosis. In addition, HIV-infection per se increases the risk of Non Alcoholic Fatty Liver Disease (NAFLD) and antiretroviral drugs may cause liver failure. In HAART era HIV-infection is no longer considered a contraindication to Solid Organ Transplant (SOT) and in some cases liver transplant is the only possible therapy. Objectives: We sought to construct a frailty index based on health deficit accumulation in HIV-positive patients that underwent liver transplantion at Liver and Multivisceral Transplant Center of University of Modena and Reggio Emilia and evaluate its validity including the ability to predict mortality, incident multimorbidity, early re-hospitalization, graft rejection and immunologic gain. Design and methods: This is an analysis of data from HIV-positive patients that underwent cadaveric donor liver transplantation at the Liver and Multivisceral Transplant Center of University of Modena and Reggio Emilia from June 2003 to June 2015. Thirty variables commonly collected in this setting were included in a Frailty Index (FI). Content, construct, and criterion validity of the FI were assessed. Multivariable regression models were built to investigate the ability of the FI to predict mortality, incident multimorbidity (at least three chronic disease diagnoses) early re-hospitalization, graft rejection and immunologic gain. Results: Fourty-seven HIV-positive patients underwent liver transplantation at from June 2003 to June 2015. Among them, 5 underwent combined transplant of liver and kidney. Median age at transplant was 51,2 years (IQR 45,91-54,35) and the most common indication for liver transplant was HCV-induced cirrhosis (82,9%), followed by hepatocellular carcinoma (HCC; 44,6%). Positive pre-transplant HCV-RNA predicted post-transplant mortality. Positive pre-transplant HCV-RNA and FI were associated, even if not statistically significantly (p=0.12), with early re-hospitalization. Locally Weighted Scatterplot Smoothing (LOWESS) showed a FI reduction in HIV-transplanted patients population after liver transplant. This decrement was more evident in surviving patients vs patients that would eventually die.