Invasive fungal infections following liver transplantations. Risk factors, incidence, treatment and outcome

Background: The incidence of invasive fungal infections (IFI), particularly invasive candidiasis and aspergillosis following solid organ transplantation vary from 1.4% to 42%. IFI the most commonly occurs after liver transplantation (OLT), lung and hearth transplantation and combined pancreas and kidney transplantation. But the etiology of this infection is different in case of hearth transplantation (dominating aspergillosis), liver transplantation (almost equal aspergillosis and candidiasis) and pancreatic transplant (dominating candidiasis). Mortality related to IFI is dependent of the type of transplant and vary from 3 to 100% of cases. The results of the treatment very much depend of the time of diagnosis and early start of selected therapy. Therefore the diagnosis has to be based on clinical data and suspicions based on known risk factors. It is very well known which factors contribute to IFI episodes. So far multiple factors are listed; among them: immunodeficiency, type and time of surgical procedure, type of anastomosis (i.e. biliary anastomosis), intraoperative blood lost, rate of rejection, presence of central venous access and retransplantation were documented by many authors over the last years. The other analyzed independent factors described by other authors were thrombocytopenia (represents subgroup of liver transplant patients susceptible to early major infections) and hepatic iron overload.
Material/Methods: The incidence of fungal infection at our institution was  assessed over the time period from July'2000 to December'2007. The retrospective analysis of 208 consecutive OLT was undertaken to evaluate incidence, risk factors, clinical course, and outcome of fungal infections. 39 recipients out of the study group (18.7%) were transplanted as HU cases and 7 (3.4%) received the second transplant. Piperacylin/Tazobactam or Imipenem (in urgent transplantation) were used as standard antibiotic perioperative prophylaxis. All OLT recipients received Flukonazol perioperatively for10 to 14 days. Selective digestive decontamination (SDD) is used routinely at our institution (consist of Amikin and Nystatine).
Results: Infections involving Aspergillus (6 cases), Candida (22 cases), Pneumocystis carini (1 case) and Cryptococcus (1 case) were observed in 15.4% (32/208) of our recipients. Except for two cases (Cryptococcus encephalitis at 3 months following OLTx and Pneumocystis carini pneumonia 2 months after OLTx) all of the episodes (30) developed during the first postoperative month. All cases of lung aspergillosis (6 cases) developed in patients with longstanding cholestasis prior to transplantation. In one case additionally post transplant extra hepatic bile duct necrosis requiring reconstruction of biliary anastomosis preceded pneumonia (Aspergillus). In 3 cases pulses of methyl-prednisolone were used for episode of acute rejection. Apart from that, none of the potential risk factors for fungal infections described by other authors was noted in our patients. 5 out of 6 aspergillosis cases survived on combined (2 drugs) antifungal therapy. Recipient diagnosed Cryptococcus encephalitis died. All cases with UTI (18)/ respiratory (6) candidiasis survived.
Conclusions: Early diagnosis and prompt treatment is detrimental for patient's survival.

Keywords: Transplantation, Organ Transplantation