Invasive fungal infections in acute and chronic liver impairment: A systematic review

Abstract

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.

Interpretable machine learning for predicting risk of invasive fungal infection in critically ill patients in the intensive care unit: A retrospective cohort study based on MIMIC-IV database

“…Kupffer cells in the liver continuously monitor infection events in the body and contribute to the antifungal response through clearance functions and cytokine release (50). In patients with liver dysfunction, monocytes and macrophages express high levels of the MER receptor tyrosine kinase, which suppresses the response to lipopolysaccharides and microbes, resulting in immunodeficiency and an increased susceptibility to IFI (51,52). Our research findings are consistent with this, suggesting that patients with liver disease are more vulnerable to IFI.…”

Acute Invasive Pulmonary Aspergillosis: Clinical Presentation and Treatment

“…However, IA remains an important life-threatening fungal infection, occurring in 5 to 14% of critically ill patients with ESLD, mainly in Child C cirrhosis. 9,52 In SAH, reported incidences are even higher: 16 to 42%. 53,54 Despite antifungal treatment, the prognosis is bad: mortality rates reach 70 to 100% in most case series.…”

“…53,54 Despite antifungal treatment, the prognosis is bad: mortality rates reach 70 to 100% in most case series. 9,52,54,55…”

Survival Fate of Hepatic Stem/Progenitor and Immune Cells in a Liver Fibrosis/Cirrhosis Animal Model and Clinical Implications

“…With this, we would like to give a better representative example of cirrhosis-mediated liver failure, acute-on-chronic liver failure (ACLF), a syndrome characterized by acute decompensation of cirrhosis, hepatic and/or extrahepatic organ failures and high short-term mortality [51], as well as the most severe immune alterations in the patients with this disease [51]. Patients with liver cirrhosis who develop these stages/diseases combine the highest grade of systemic inflammation [41] and severe immunodeficiency [52], which leads not only to an increased risk of infections but also to pathogenic liver organ failure [53] or cancers (HCC) [54,55]; however, how these phenomena underlie biological substrates is unclear. One study shows for the first time that depression or anxiety grade of patients with liver cirrhosis is correlated with CD8 + T-cell signs [56], suggesting that an imbalance of CD8 + T cells may be a factor facilitating neurological disease patients with cirrhotic liver disease.…”