Liver Transplantation in Patients with Pretransplant Aspergillus Colonization: Is It Safe To Proceed?

BACKGROUND: Patients with end-stage liver disease and pretransplant Aspergillus colonization are problematic for determining liver transplant candidacy and timing of transplantation due to concerns for posttransplant invasive aspergillosis. METHODS: We performed a retrospective review of the medical and laboratory records of all adult patients (>/=18 years of age) who underwent liver transplantation with pretransplant Aspergillus colonization at the Ronald Reagan UCLA 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 (11/27, 40.7%), dialysis (22/27, 81.5%), corticosteroid therapy (12/27, 44.4%), intensive care unit stay (27/27, 100%), and median MELD score of 39. Only 22.2% (6/27) received pretransplant antifungal agents (median duration, 5 days), while 100% (27/27) received posttransplant antifungal prophylaxis (voriconazole 81.4%, 22/27; echinocandin 14.8%, 4/27; voriconazole plus echinocandin 3.7%, 1/27) for median duration of 85 days. Posttransplant invasive fungal infection occurred in 14.8% (4/27; aspergillosis 3, mucormycosis 1). Both 6-month and 12-month survival were 66.7% (18/27), but only 1 death was due to fungal infection. Other causes of death were liver graft failure, intraabdominal complications, and malignancy. CONCLUSION: 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.