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Abstract：
Antiretroviral therapy (ART) has led to a decline in human immunodeficiency virus (HIV)-related mortality, but comorbidities, including organ dysfunction, are increasingly the focus of care. Heart transplant (HT) is a very effective therapeutic strategy for end-stage heart failure (HF); however, clinicians may be hesitant due to concerns of complex drug-drug interactions (DDIs) between ART and HT immunosuppressive regimens and the potential impact of ART on long-term HT outcomes. In this report, we describe long-term (76-month) follow-up of a patient with HIV-positive status who underwent orthotopic HT with special emphasis on complex drug interactions.
A 58-year-old man with HIV-1 developed ischemic cardiomyopathy, progressed to end-stage HF and underwent orthotopic HT. To avoid DDIs with planned immunosuppressive therapies, the ART regimen was modified to consist of lamivudine, tenofovir disoproxil fumarate, rilpivirine, and raltegravir. Following HT, the patient\'s immunosuppression consisted of tacrolimus and mycophenolate mofetil. He has had normal cardiac function and no opportunistic infections and was subsequently switched to tenofovir alafenamide, emtricitabine, and bictegravir in combination for convenience. Serial HIV-1 RNA blood levels were constantly below the limit of quantification, and his CD4 count remained above 200 cells/mm3 (30-35%). Several DDIs were identified and addressed; however, his long-term post-HT complications included one episode of asymptomatic acute cellular rejection, adenocarcinoma of the prostate, basal cell carcinoma, cardiac allograft vasculopathy, and peripheral neuropathy.
The clinical outcome of this case supports the conclusion of previously published reports, summarized here within, demonstrating that HIV-1 positive status should not preclude HT in carefully selected individuals. Both addressing potential DDIs prior to HT and long-term monitoring for routine post-transplant complications and secondary and incidental malignancies are imperative.
A 58-year-old man with HIV-1 developed ischemic cardiomyopathy, progressed to end-stage HF and underwent orthotopic HT. To avoid DDIs with planned immunosuppressive therapies, the ART regimen was modified to consist of lamivudine, tenofovir disoproxil fumarate, rilpivirine, and raltegravir. Following HT, the patient\'s immunosuppression consisted of tacrolimus and mycophenolate mofetil. He has had normal cardiac function and no opportunistic infections and was subsequently switched to tenofovir alafenamide, emtricitabine, and bictegravir in combination for convenience. Serial HIV-1 RNA blood levels were constantly below the limit of quantification, and his CD4 count remained above 200 cells/mm3 (30-35%). Several DDIs were identified and addressed; however, his long-term post-HT complications included one episode of asymptomatic acute cellular rejection, adenocarcinoma of the prostate, basal cell carcinoma, cardiac allograft vasculopathy, and peripheral neuropathy.
The clinical outcome of this case supports the conclusion of previously published reports, summarized here within, demonstrating that HIV-1 positive status should not preclude HT in carefully selected individuals. Both addressing potential DDIs prior to HT and long-term monitoring for routine post-transplant complications and secondary and incidental malignancies are imperative.
摘要：
背景：抗逆转录病毒疗法（ART）导致人类免疫缺陷病毒（HIV）相关死亡率下降，但是合并症,包括器官功能障碍,越来越成为护理的焦点。心脏移植（HT）是治疗终末期心力衰竭（HF）的一种非常有效的治疗策略；由于担心ART和HT免疫抑制方案之间的复杂药物-药物相互作用(DDI)以及ART对长期HT结局的潜在影响,临床医生可能会犹豫不决.在这份报告中,我们描述了一名HIV阳性患者接受原位HT的长期(76个月)随访,特别强调复杂的药物相互作用.
方法：一名58岁的HIV-1患者出现缺血性心肌病，进展为终末期HF并接受原位HT。为了避免使用计划的免疫抑制疗法进行DDI，ART方案被修改为由拉米夫定组成，富马酸替诺福韦酯，利匹韦林,还有Raltegravir.在HT之后，患者的免疫抑制包括他克莫司和霉酚酸酯。他的心功能正常，没有机会性感染，随后改用替诺福韦艾拉酚胺，恩曲他滨,和bictegravir结合方便。连续的HIV-1RNA血液水平一直低于定量极限，并且他的CD4计数保持在200个细胞/mm3以上（30-35％）。确定并解决了几个DDI；但是，他的长期HT后并发症包括一次无症状的急性细胞排斥反应，前列腺腺癌，基底细胞癌,心脏移植血管病变，和周围神经病变。
结论：该病例的临床结果支持以前发表的报告的结论，总结在这里，在精心挑选的个体中，证明HIV-1阳性状态不应排除HT。必须在HT之前解决潜在的DDI，并长期监测常规移植后并发症以及继发性和偶然恶性肿瘤。
方法：一名58岁的HIV-1患者出现缺血性心肌病，进展为终末期HF并接受原位HT。为了避免使用计划的免疫抑制疗法进行DDI，ART方案被修改为由拉米夫定组成，富马酸替诺福韦酯，利匹韦林,还有Raltegravir.在HT之后，患者的免疫抑制包括他克莫司和霉酚酸酯。他的心功能正常，没有机会性感染，随后改用替诺福韦艾拉酚胺，恩曲他滨,和bictegravir结合方便。连续的HIV-1RNA血液水平一直低于定量极限，并且他的CD4计数保持在200个细胞/mm3以上（30-35％）。确定并解决了几个DDI；但是，他的长期HT后并发症包括一次无症状的急性细胞排斥反应，前列腺腺癌，基底细胞癌,心脏移植血管病变，和周围神经病变。
结论：该病例的临床结果支持以前发表的报告的结论，总结在这里，在精心挑选的个体中，证明HIV-1阳性状态不应排除HT。必须在HT之前解决潜在的DDI，并长期监测常规移植后并发症以及继发性和偶然恶性肿瘤。
