Preliver Transplant Aspergillus Colonization: An Ounce of Prevention

医学 移植 曲菌病 肝移植 围手术期 内科学 入射(几何) 伏立康唑 茴香菌素 外科 抗真菌 米卡芬金 免疫学 物理 皮肤病科 光学
作者
Marcus R. Pereira
出处
期刊:Transplantation [Wolters Kluwer]
卷期号:105 (3): 474-475
标识
DOI:10.1097/tp.0000000000003277
摘要

Invasive Aspergillus (IA) remains the second most common invasive fungal infection among liver transplant recipients, with an estimated incidence ranging between 1% and 9%.1 Risk factors are reasonably well established and include perioperative renal replacement therapy, model for end-stage liver disease (MELD) >30 at transplant, cytomegalovirus infection, and retransplantation, the latter being the highest risk for IA posttransplant.1-4 Initially described as an early opportunistic infection, more recent epidemiological studies have revealed a shift toward the later postoperative period (>3 mo). Although uncommon, IA is associated with significant morbidity and mortality, especially when occurring early after transplant.5 Targeted prophylaxis among patients at risk has been studied, using a variety of antifungal agents such as echinocandins or azoles, and appears effective in preventing or at least in delaying onset of IA.6,7 Recent guidelines recommend such approach for liver transplant candidates at risk.1 In this issue of Transplantation, Winston et al report on the outcome of 27 postliver transplant patients with pretransplant Aspergillus colonization during a 5-year period in a single center.8 All patients, except 1, were found to be colonized in the respiratory tract shortly before transplant. While only 6 patients received treatment for this before transplant, all received antifungal prophylaxis with activity against Aspergillus postoperatively, most with voriconazole, for a median of 85 days. After transplant, only 3 patients developed IA, 2 within 6 days of transplant, and shortly after being initiated on prophylaxis, perhaps indicating that the patients could have had active infection going into the transplant. Overall, 1-year survival was 66.7% (21/27 patients), and only 1 death was attributed directly to IA. Meanwhile, a control group of liver transplant recipients with a similar MELD score but not colonized had a 1-year survival of 81.5% (P = 0.01). Despite this difference, the authors conclude that these patients can still undergo successful transplantation if given adequate prophylaxis. Evidence is accumulating that voriconazole prophylaxis is safe and effective for high-risk patients undergoing liver transplant, and this article is an important contribution to that literature.6,7 There were no reported adverse events due to voriconazole, and patients seem to have tolerated it well. More importantly, this study also highlights the potential feasibility of proceeding with transplant even when Aspergillus colonization has been identified. For patients with cystic fibrosis who are colonized with Aspergillus pretransplant, studies have shown that outcomes are similar to those who are not colonized.9 Certainly, these results may be due to source control (ie, removing colonized lungs) as much as antifungal therapy. Nevertheless, such data have not been previously available in liver transplant, leading to the potential denial of life-saving procedure due to a perceived high risk of infectious complications afterward. Given that, this study provides important information for transplant clinicians in that prophylaxis seems to decrease the rate of IA, or at least postpones it to a time when the recipient is possibly stronger. This study requires careful interpretation, however. Since there was no routine testing for fungal colonization, some patients with colonization could have been missed. Similarly, defining IA in retrospective studies may be problematic and cases may have been either missed or incorrectly diagnosed. As the authors suggest, the small sample size significantly limited further analysis and further identification of risk factors for the lower 1-year survival was not possible. More importantly, although the comparison group used for analysis was matched for MELD score, the groups were otherwise markedly different including a much higher rate of patients undergoing retransplantation and on associated pretransplant immunosuppression, renal disease requiring dialysis and longer ICU stay in the colonized group. These are important factors because they most likely impacted the survival rate in the colonized group, particularly those undergoing retransplants. As a reference, 1-year survival rates in patients undergoing retransplantation have been reported to be near 75%, which would be similar to the colonized patients.10 Therefore, it may be that, for patients undergoing retransplantation, Aspergillus colonization does not significantly impact survival beyond baseline outcomes, whereas it may be an important marker, among other risk factors, for poor outcomes in surrogate patients undergoing the first transplant. As such, screening for Aspergillus colonization in liver transplant candidates is an intriguing question. Further studies on who should be tested and how they should be managed are much needed. As organ transplantation remains a scarce resource, recipient selection to maximize the potential benefit of each donor graft remains of primary concern to the transplant community. As infection remains among the most common causes of morbidity and mortality following liver transplant, there has been increased attention paid to the evaluation of pretransplant colonization with both fungi and multidrug-resistant bacteria with subsequent targeted prophylaxis in the perioperative period. Such initiatives, and further research, seem worthwhile in that they open the way for candidates with complex medical histories to safely proceed with transplantation.
最长约 10秒,即可获得该文献文件

科研通智能强力驱动
Strongly Powered by AbleSci AI
更新
PDF的下载单位、IP信息已删除 (2025-6-4)

科研通是完全免费的文献互助平台,具备全网最快的应助速度,最高的求助完成率。 对每一个文献求助,科研通都将尽心尽力,给求助人一个满意的交代。
实时播报
1秒前
2秒前
大模型应助Ki_Ayasato采纳,获得10
3秒前
科研通AI2S应助嘞是举仔采纳,获得10
3秒前
4秒前
谨慎的晓蕾完成签到 ,获得积分10
4秒前
5秒前
呃呃完成签到,获得积分10
5秒前
Rabbit发布了新的文献求助10
6秒前
7秒前
DDEEE发布了新的文献求助10
8秒前
慕青应助大喵采纳,获得10
8秒前
丘比特应助Xian采纳,获得10
9秒前
公冶笑白发布了新的文献求助10
10秒前
11秒前
Ploaris发布了新的文献求助10
11秒前
研友_Z63kg8发布了新的文献求助20
12秒前
呃呃发布了新的文献求助10
12秒前
调皮的千万完成签到,获得积分10
12秒前
Fengliguantou发布了新的文献求助10
13秒前
hecheng0511完成签到,获得积分10
13秒前
J.发布了新的文献求助20
15秒前
ShenLi应助QDU采纳,获得10
17秒前
领导范儿应助小垃圾采纳,获得10
22秒前
研友_Z63kg8完成签到,获得积分10
22秒前
25秒前
静一静完成签到,获得积分10
25秒前
26秒前
26秒前
ycccccc完成签到 ,获得积分10
26秒前
李健应助huangyikun采纳,获得10
27秒前
27秒前
小药同学完成签到,获得积分10
28秒前
宝贝丫头发布了新的文献求助10
29秒前
白桦林泪发布了新的文献求助10
30秒前
小药同学发布了新的文献求助10
30秒前
31秒前
嘞是举仔发布了新的文献求助10
31秒前
感性发布了新的文献求助10
32秒前
32秒前
高分求助中
A new approach to the extrapolation of accelerated life test data 1000
ACSM’s Guidelines for Exercise Testing and Prescription, 12th edition 500
‘Unruly’ Children: Historical Fieldnotes and Learning Morality in a Taiwan Village (New Departures in Anthropology) 400
Indomethacinのヒトにおける経皮吸収 400
Phylogenetic study of the order Polydesmida (Myriapoda: Diplopoda) 370
基于可调谐半导体激光吸收光谱技术泄漏气体检测系统的研究 350
Robot-supported joining of reinforcement textiles with one-sided sewing heads 320
热门求助领域 (近24小时)
化学 材料科学 医学 生物 工程类 有机化学 生物化学 物理 内科学 纳米技术 计算机科学 化学工程 复合材料 遗传学 基因 物理化学 催化作用 冶金 细胞生物学 免疫学
热门帖子
关注 科研通微信公众号,转发送积分 3989797
求助须知:如何正确求助?哪些是违规求助? 3531910
关于积分的说明 11255394
捐赠科研通 3270563
什么是DOI,文献DOI怎么找? 1805008
邀请新用户注册赠送积分活动 882157
科研通“疑难数据库(出版商)”最低求助积分说明 809190