Outcome of Liver Transplantation for Critically Ill Acute on Chronic Liver Failure Recipients Complicated With Pretransplant Invasive Pulmonary Aspergillosis

ABSTRACT Background Patients with acute‐on‐chronic liver failure (ACLF) are susceptible to fungal infections. However, pretransplant invasive pulmonary Aspergillosis (IPA) is generally considered a relative contraindication for liver transplantation (LT). Methods We conducted a multi‐center retrospective study involving ACLF adult patients with pretransplant IPA who underwent LT at four hospitals between January 2021, and June 2024. For comparative analysis, we included a control group of ACLF patients without preoperative Aspergillus infection during the same period, from the Renji Hospital cohort with matching approach. Posttransplant outcomes were then evaluated and compared between the two groups (ACLF patients with IPA vs. those without IPA). Results A total of 21 patients who had IPA before LT was identified. The mean age was 46.7 ± 9.2 years. The mean MELD score of these patients was 28.6. Most (71.4%, 15/21) patients received antifungal therapy immediately after the diagnosis of IPA. Twelve patients received voriconazole, one received isavuconazole, one received posaconazole, one received amphotericin B plus caspofungin and isavuconazole, the remaining six patients did not receive any antifungal drugs before LT. The median duration of antifungal therapy was 9 days (range: 0.5–34.5 days) before transplantation, overall median duration of antifungal treatment was 58 days (range: 22–83). The 3‐month (38.1%, 8/21) and 12‐month mortality (42.9%, 9/21) were significantly higher than patients without pretransplant IPA ( p = 0.049 and p = 0.026, respectively). Conclusions The survival of LT for ACLF patients with pretransplant IPA was suboptimal, although they had received appropriate antifungal treatment within the peri‐transplantation period. Multidisciplinary discussions before transplantation are necessary on case‐by‐case. image