Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen, Universität München, Munich, Germany.
Division of Infectious Diseases, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil.
Mycoses. 2022 Feb;65(2):140-151. doi: 10.1111/myc.13403. Epub 2021 Dec 8.
Patients with acute and chronic liver impairment are susceptible to invasive fungal infections such as candidemia and invasive pulmonary aspergillosis as a result of cirrhosis-associated immune dysfunction, humoral immunodeficiency, cell-mediated dysfunction and systemic inflammation. Besides classical risk factors for invasive fungal infection, acute-on-chronic liver failure, corticosteroid use, gastrointestinal bleeding, and prophylactic use of antibiotics are all additional conditions which are related to the potential development of fungal infections. Therefore, high-risk patients should be carefully followed by microbiological surveillance including cultures but also by imaging and fungal biomarkers for providing early diagnosis. Echinocandins are still the mainstay and first line antifungal therapy in cases of invasive candidiasis. Due to concerns of liver toxicity and in cases of renal impairment liposomal amphotericin B is a suitable alternative to voriconazole in patients with invasive pulmonary aspergillosis. Although, data of isavucoanzole and posaconazole use in those patients are also promising more specific studies in the subgroup of patients with liver impairment are needed. Especially, due to the late diagnosis and multiple organ dysfunction usually present in patients with liver impairment morbidity and mortality rates remain high. Based on the broad spectrum of diverse reports with varying content and quality and in some cases lack of evidence we performed a systematic review on this topic.
患有急性和慢性肝损伤的患者由于肝硬化相关免疫功能障碍、体液免疫缺陷、细胞介导功能障碍和全身炎症而易发生侵袭性真菌感染，如念珠菌血症和侵袭性肺曲霉病。除了侵袭性真菌感染的经典危险因素外，慢加急性肝衰竭、皮质类固醇的使用、胃肠道出血和预防性使用抗生素等都是与真菌感染潜在发展相关的其他条件。因此，高危患者应通过微生物学监测（包括培养物）以及影像学和真菌生物标志物进行仔细监测，以提供早期诊断。棘白菌素类药物仍然是侵袭性念珠菌病的主要和一线抗真菌治疗药物。由于担心肝毒性，并且在肾功能损害的情况下，两性霉素 B 脂质体是侵袭性肺曲霉病患者替代伏立康唑的合适选择。尽管在这些患者中使用伊曲康唑和泊沙康唑的数据也很有希望，但仍需要在肝损伤亚组患者中进行更具体的研究。特别是由于肝损伤患者的诊断较晚和通常存在多器官功能障碍，发病率和死亡率仍然很高。基于广泛的不同报告，内容和质量各不相同，在某些情况下缺乏证据，我们对此主题进行了系统评价。
