Invasive pulmonary aspergillosis (IPA) before liver transplantation increases mortality post-transplant by ~4x, according to Fang Chen and colleagues. Mortality with and without IPA was 38.1% vs 10.5% at 3 months (p= 0.049) and 42.9% vs 10.5% at 12 months (p = 0.026), respectively. These high mortality figures were despite antifungal therapy in 67% for a median duration of 9 days (range: 0.5–34.5 days) before transplantation.
Amongst participants with IPA, intracranial haemorrhage, septic shock, and multiorgan failure accounted for fatal outcomes in 9.5%, 19.0% and 14.3% of the cases, respectively. This was despite receiving appropriate antifungal treatment within the peri-transplantation period, which underscores the intricacies involved in the management of patients with liver failure complicated with invasive aspergillosis. The authors recommended multidisciplinary discussions on a case-by-case basis when considering a liver transplant.
Invasive aspergillosis (IA) in patients with chronic liver disease carries a terrible prognosis. Worse outcomes have been reported in non-transplant series evaluating patients with chronic liver disease complicated with IA. A survival rate of 0% in patients with alcoholic hepatitis compared with 53% in those without IA at 3 months was reported by Gustot et al., despite antifungal treatment. Similarly, in a German study by Lahmer and colleagues, the mortality rate was significantly higher in probable IPA patients (100% versus 65%) compared with patients without IPA. However, as shown in other studies by Yuang et al., Liu et al., and Abe et al., early recognition of predictors of IPA in patients with acute on chronic liver failure and the timely initiation of appropriate treatment measures may improve outcomes. This study by Chen and colleagues indicates that IPA in patients on the transplant waiting list need not be a contraindication to transplantation, but outcomes are suboptimal compared with those being transplanted without IPA.
Image courtesy: Dr Bassey Ekeng.