Department of Internal Medicine, Blessing Physician Services, Quincy, IL, USA.
Liver Transpl. 2012 Sep;18(9):1100-9. doi: 10.1002/lt.23467.
Invasive fungal infections (IFIs) are associated with a high mortality rate for liver transplantation (LT) recipients. To study the incidence of and risk factors for IFIs in LT recipients and the associated mortality rates, we retrospectively reviewed the records of first-time deceased donor LT recipients (January 2003 to December 2007). The incidence of IFIs was 12%. Non-albicans Candida species accounted for 55% of IFIs; 50% of these IFIs were Candida parapsilosis. Only 43% of Candida isolates were fluconazole-susceptible (minimum inhibitory concentration ≤ 8 μ/mL). All C. parapsilosis isolates were fluconazole-resistant, and this coincided with a surge of these isolates during a peak period of LT. Factors associated with IFIs included a creatinine level > 2 mg/mL [hazard ratio (OR) = 2.4, 95% confidence interval (CI) = 1.2-5.0, P = 0.01], a Model for End-Stage Liver Disease score > 25 (OR = 2.4, 95% CI = 1.2-4.9, P = 0.02), pretransplant fungal colonization (OR = 7.0, 95% CI = 3.2-15.3, P < 0.001), and a daily prophylactic fluconazole dosage < 200 mg (OR = 2.8, 95% CI = 1.1-7.4, P = 0.03). According to a multivariate analysis, only pretransplant fungal colonization was associated with IFIs (OR = 7.8, 95% CI = 3.9-16.2, P < 0.001). The 1-year patient survival rates with and without IFIs were 41% and 80%, respectively, and the survival rates with C. parapsilosis, other non-albicans Candida, and Candida albicans IFIs were 28%, 50%, and 75%, respectively. In conclusion, IFIs after LT (especially non-albicans Candida species and fluconazole-resistant C. parapsilosis) were associated with reduced survival. The risk factors highlight the importance of pretransplant risk assessments. The identification of pretransplant fungal colonization may allow for risk modifications before or at the time of LT. Additionally, the number of LT procedures and prophylactic strategies may affect institutional outbreaks of resistant Candida strains.
侵袭性真菌感染（IFI）与肝移植（LT）受者的高死亡率相关。为了研究 LT 受者IFI 的发生率、危险因素和相关死亡率，我们回顾性分析了首次接受已故供体 LT 受者的记录（2003 年 1 月至 2007 年 12 月）。IFI 的发生率为 12%。非白念珠菌属念珠菌占 IFI 的 55%；其中 50%的 IFI 为近平滑念珠菌。只有 43%的念珠菌分离株对氟康唑敏感（最低抑菌浓度≤8μg/mL）。所有近平滑念珠菌分离株均对氟康唑耐药，这与 LT 高峰期这些分离株的激增相吻合。IFI 的相关因素包括肌酐水平>2mg/mL[风险比（OR）=2.4，95%置信区间（CI）=1.2-5.0，P=0.01]，终末期肝病模型评分>25（OR=2.4，95%CI=1.2-4.9，P=0.02），移植前真菌定植（OR=7.0，95%CI=3.2-15.3，P<0.001），和每日预防性氟康唑剂量<200mg（OR=2.8，95%CI=1.1-7.4，P=0.03）。根据多变量分析，只有移植前真菌定植与 IFI 相关（OR=7.8，95%CI=3.9-16.2，P<0.001）。IFI 患者和无 IFI 患者的 1 年生存率分别为 41%和 80%，近平滑念珠菌、其他非白念珠菌属念珠菌和白念珠菌 IFI 的生存率分别为 28%、50%和 75%。总之，LT 后 IFI（尤其是非白念珠菌属念珠菌和氟康唑耐药的近平滑念珠菌）与存活率降低相关。危险因素强调了移植前风险评估的重要性。移植前真菌定植的鉴定可能允许在 LT 之前或当时进行风险修改。此外，LT 手术数量和预防策略可能会影响耐药念珠菌株的机构暴发。
