肝移植患者移植前曲霉菌定植：继续进行是否安全？
Liver Transplantation in Patients With Pretransplant Aspergillus Colonization: Is It Safe to Proceed?
机构信息
Division of Liver and Pancreas Transplantation, Department of Surgery, Ronald Reagan University of California, Los Angeles Medical Center, Los Angeles, CA.
David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
出版信息
Transplantation. 2021 Mar 1;105(3):586-592. doi: 10.1097/TP.0000000000003276.
BACKGROUND
Patients with end-stage liver disease and pretransplant Aspergillus colonization are problematic for determining liver transplant candidacy and timing of transplantation because of concerns for posttransplant invasive aspergillosis.
METHODS
We performed a retrospective review of the medical and laboratory records of all adult patients (aged ≥18 y) who underwent liver transplantation with pretransplant Aspergillus colonization at the Ronald Reagan University of California, Los Angeles, Medical Center from January 1, 2010, to December 31, 2015.
RESULTS
A total of 27 patients who had Aspergillus colonization (respiratory tract 26, biliary tract 1) before liver transplantation were identified. Pretransplant characteristics included previous liver transplant (11 of 27, 40.7%), dialysis (22 of 27, 81.5%), corticosteroid therapy (12 of 27, 44.4%), intensive care unit stay (27 of 27, 100%), and median model for end-stage liver disease score of 39. Only 22.2% (6 of 27) received pretransplant antifungal agents (median duration, 5 d), whereas 100% (27 of 27) received posttransplant antifungal prophylaxis (voriconazole 81.4%, 22 of 27; echinocandin 14.8%, 4 of 27; voriconazole plus echinocandin 3.7%, 1 of 27) for median duration of 85 d. Posttransplant invasive fungal infection occurred in 14.8% (4 of 27; aspergillosis 3, mucormycosis 1). Both 6-month and 12-month survival were 66.7% (18 of 27), but only 1 death was due to fungal infection. Other causes of death were liver graft failure, intraabdominal complications, and malignancy.
CONCLUSIONS
A substantial number of patients with pretransplant Aspergillus colonization can still undergo successful liver transplantation if they are otherwise suitable candidates and receive appropriate antifungal prophylaxis. Posttransplant outcome in these patients is determined mostly by noninfectious complications and not fungal infection. Pretransplant Aspergillus colonization alone should not necessarily preclude or delay liver transplantation.
背景
对于患有终末期肝病和移植前曲霉菌定植的患者，由于担心移植后侵袭性曲霉菌病，确定肝移植候选者和移植时间存在问题。
方法
我们对 2010 年 1 月 1 日至 2015 年 12 月 31 日期间在加利福尼亚大学洛杉矶分校罗纳德·里根医学中心接受肝移植且移植前有曲霉菌定植的所有成年患者（年龄≥18 岁）的医疗和实验室记录进行了回顾性分析。
结果
共确定了 27 例肝移植前有曲霉菌定植（呼吸道 26 例，胆道 1 例）的患者。移植前特征包括既往肝移植（27 例中的 11 例，40.7%）、透析（27 例中的 22 例，81.5%）、皮质类固醇治疗（27 例中的 12 例，44.4%）、重症监护病房住院（27 例，100%）和中位终末期肝病模型评分 39 分。只有 22.2%（27 例中的 6 例）接受了移植前抗真菌治疗（中位时间 5 天），而 100%（27 例）接受了移植后抗真菌预防治疗（伏立康唑 81.4%，27 例中的 22 例；棘白菌素 14.8%，27 例中的 4 例；伏立康唑联合棘白菌素 3.7%，27 例中的 1 例），预防时间中位数为 85 天。移植后侵袭性真菌感染发生率为 14.8%（27 例中的 4 例；曲霉病 3 例，毛霉病 1 例）。6 个月和 12 个月的存活率分别为 66.7%（27 例中的 18 例），但只有 1 例死亡是由真菌感染引起的。其他死亡原因是肝移植失败、腹腔内并发症和恶性肿瘤。
结论
如果其他方面适合候选者且接受适当的抗真菌预防治疗，仍可成功进行大量有移植前曲霉菌定植的患者的肝移植。这些患者的移植后结果主要由非感染性并发症而不是真菌感染决定。单纯移植前曲霉菌定植不一定会排除或延迟肝移植。
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