Invasive fungal infection before and after liver transplantation

Abstract

Invasive infections are a major complication before liver transplantation (LT) and in the early phase after surgery. There has been an increasing prevalence of invasive fungal disease (IFD), especially among the sickest patients with decompensated cirrhosis and acute-on-chronic liver failure, who suffer from a profound state of immune dysfunction and receive intensive care management. In such patients, who are listed for LT, development of an IFD often worsens hepatic and extra-hepatic organ dysfunction, requiring a careful evaluation before surgery. In the post-transplant setting, the burden of IFD has been reduced after the clinical advent of antifungal prophylaxis, even if several major issues still remain, such as duration, target population and drug type(s). Nevertheless, the development of IFD in the early phase after surgery significantly impairs graft and patient survival. This review outlines presentation, prophylactic and therapeutic strategies, and outcomes of IFD in LT candidates and recipients, providing specific considerations for clinical practice.

Keywords: Acute liver failure; Acute-on-chronic liver failure; Candidemia; Cirrhosis; Invasive fungal infection; Sepsis.

Figure 1

CT-scan. A: Chest CT-scan of a young male patient with hepatitis B virus related cirrhosis and acute-on-chronic liver failure, waitlisted for liver transplantation, who developed invasive aspergillosis; B: He was temporarily withdrawn from the waiting list, and received antifungal treatment for a total of 13 d, with a clinical and radiological improvement. He subsequently died of bacterial super-infection before liver transplantation.