Case Control Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Sep 18, 2023; 13(5): 264-275
Published online Sep 18, 2023. doi: 10.5500/wjt.v13.i5.264
Invasive aspergillosis in liver transplant recipients, an infectious complication with low incidence but significant mortality
Azam Farahani, Fereshteh Ghiasvand, Setareh Davoudi, Zahra Ahmadinejad
Azam Farahani, Fereshteh Ghiasvand, Setareh Davoudi, Department of Infectious Diseases, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran 1478714466, Iran
Zahra Ahmadinejad, Liver Transplantation Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran 1478714466, Iran
Author contributions: Ahmadinejad Z designed the research study, translate the article into English and revised the manuscript according to the reviewer comments; Farahani A performed the research, analyzed the data and prepared the draft of manuscript in Persian language; Ghiasvand F and Davoudi S scientifically and grammatically edit the translated manuscript; All authors have read and approve the final manuscript.
Institutional review board statement: The study was reviewed and approved by the Institutional research ethics committee, school of medicine, Tehran university of medical sciences (Approval No. IR.TUMS.MEDICINE.REC.1399.874).
Informed consent statement: Informed consent was waived by the EBR due to retrospective pattern of the study. However the questionnaires were anonymous.
Conflict-of-interest statement: There is no any conflict of interest.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Zahra Ahmadinejad, MD, Full Professor, Liver Transplantation Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, KESHAVARZ Blvd, Dr Gharib Street, Tehran 1478714466, Iran.
Received: June 28, 2023
Peer-review started: June 28, 2023
First decision: August 4, 2023
Revised: August 17, 2023
Accepted: September 4, 2023
Article in press: September 4, 2023
Published online: September 18, 2023

Infections, including invasive fungal infections (IFIs), are among the leading causes of mortality in liver transplant recipients during the first year post-transplantation.


To investigate the epidemiology, clinical manifestations, risk factors, treatment outcomes, and mortality rate of post-liver transplantation invasive aspergillosis (IA).


In this case-control study, 22 patients with IA were identified by reviewing the archived and electronic medical records of 850 patients who received liver transplants at the Imam Khomeini Hospital complex in Tehran, Iran, between 2014 and 2019. The control group comprised 38 patients without IA infection matched for age and sex. The information obtained included the baseline characteristics of liver transplant patients, operative reports, post-transplantation characteristics of both groups and information about the fungal infection of the patient group.


The prevalence rate of IA among liver transplant recipients at Imam Khomeini Hospital was 2.7%. The risk factors of IA among studied patients included high serum creatinine levels before and post-transplant, renal replacement therapy, antithymocyte globulin induction therapy, post-transplant bile leakage, post-transplant hepatic artery thrombosis, repeated surgery within 30 d after the transplant, bacterial pneumonia before the aspergillosis diagnosis, receiving systemic antibiotics before the aspergillus infection, cytomegalovirus infection, and duration of post-transplant hospitalization in the intensive care unit. The most prevalent form of infection was invasive pulmonary aspergillosis, and the most common chest computed tomography scan findings were nodules, pleural effusion, and the halo sign. In the case group, prophylactic antifungal therapy was administered more frequently than in the control group. The antifungal therapy response rate at 12 wk was 63.7%. The 3- and 12- mo mortality rates of the patients with IA were 36.4% and 45.4%, respectively (compared with the mortality rate of the control group in 12 mo, which was zero).


In this study, the prevalence of IA among liver transplant recipients was relatively low. However, it was one of the leading causes of mortality following liver transplantation. Targeted antifungal therapy may be a factor in the low incidence of infections at our facility. Identifying the risk factors of IFIs, maintaining an elevated level of clinical suspicion, and initiating early antifungal treatment may significantly improve the prognosis and reduce the mortality rate of liver transplant recipients.

Keywords: Aspergillosis, Cytomegalovirus infection, Immunosuppression therapy, Liver transplantation, Risk factors, Fungal infections, Fungal pneumonia

Core Tip: In our center, invasive aspergillosis had a low incidence but a high mortality rate among liver transplant recipients. Invasive pulmonary aspergillosis was the most prevalent form of infection. Nodules, pleural effusion, and halo signs were the most commonly observed findings on chest computed tomography scans. Antifungal prophylaxis was more prevalent in the case group than in the control group. At week 6 of antifungal treatment, more than 60% of patients experienced complete recovery or relative response to therapy.