Fungal infections after liver transplantation: outcomes and risk factors revisited in the MELD era

Antifungal prophylaxis is recommended in high‐risk patients, but risk criteria remain unclear and the predictive value of Model of End‐Stage Liver Disease ( MELD ) score is unknown. In a retrospective, single‐center analysis of 667 liver transplants, potential risk factors for fungal infection were assessed, including MELD score. Antifungal prophylaxis was administered in 198 patients (29.4%). During follow‐up (mean 43.6 ± 29.6 months), 263 patients (39.4%) developed ≥1 episode of fungal infection, and 187 (28.0%) patients developed a probable or proven invasive fungal infection requiring systemic antifungal treatment. Patients receiving antifungal prophylaxis had a lower incidence of fungal infection (29.8% vs. 43.5% without prophylaxis, p < 0.001) and invasive fungal infection (17.7% vs. 32.4%, p < 0.001). One‐yr patient survival was 91%, 85% and 69%, respectively, in patients with no fungal infection, fungal colonization and treated invasive fungal infection (p < 0.001); graft survival was 88%, 85% and 66% (p < 0.001). Multivariate analysis indicated that MELD score of 20–30 or ≥30 was associated with a 2.0‐fold or 4.3‐fold increase in relative risk of fungal infection, respectively, and a 2.1‐fold or 3.1‐fold increase in relative risk of invasive fungal infection. In conclusion, liver transplant patients with a MELD score ≥20, and particularly patients with a score ≥30, are candidates for antifungal prophylaxis.