Patients with an infection before liver transplant had excellent survival outcomes despite requiring more complex post-transplant care.

“The risk of poor outcomes because of the persistence/recurrence of infections after liver transplant (LT) is a main barrier in the decision to proceed or not to LT in patients with cirrhosis and infections,” Salvatore Piano, MD, PhD, and colleagues wrote. “In fact, infections increase morbidity and mortality in the early post-transplant period, and use of immunosuppression may limit the ability of the host to counteract the pathogens. For these reasons, international guidelines state that active infections should be adequately treated before LT. However, the optimal timing of LT in patients surviving an episode of infection as well as their prioritization on LT waiting list is still to be established.”

Further, studies that examined post-LT outcomes among patients who survived an infection have conflicting results, according to Dr. Piano and colleagues. While some studies demonstrate no difference in survival for patients with versus without pre-LT infections, others indicate a higher risk for sepsis-related mortality in those with pre-LT infections, particularly if complicated by septic shock.

For a study published in JHEP Reports, the researchers examined the influence of bacterial infections within the 3 months preceding LT on post-transplant outcomes and the impact of time from infection improvement/resolution to LT on post-transplant outcomes. The single-center study, conducted from 2012 to 2018, categorized patients undergoing an LT into two groups: (1) patients surviving a bacterial infection in the 3 months prior to LT (study group) and (2) patients with no infection preceding LT (control group). Dr. Piano and colleagues obtained data on post-LT outcomes, including complications, new infections, and survival.

LT Survival Comparable With or Without Infection

The study included 466 LT recipients, most of whom (n=358) who were in the control group rather than the study group (n=108). Median age was comparable in the control group versus the study group (58 vs 56). More than 70% of patients in each group were men.

Hepatocellular carcinoma occurred more often in the control group compared with the study group. The most common cirrhosis etiology was hepatitis C virus for the control group and alcohol for the study group.

Following LT, there were higher incidences in the study group of new bacterial (57% vs 20%; P<0.001) and fungal infections (14% vs 5%; P=0.001) and septic shock (8% vs 2%; P=0.004) than in the control group. Several factors served as independent predictors of post-LT infections, including the Model for End-stage Liver Disease (MELD) score (P=0.002), alcohol-related cirrhosis (P=0.011), and bacterial infection before  LT (P<0.001).

Survival rates were comparable between the study group and control group at 1 year (88% vs 89%) and 5 years (76% vs 75%; Figure).

In our series, patients surviving an infectious episode within 3 months before LT had a higher incidence of new infections, both bacterial and fungal, a higher incidence of septic shock, and required longer ICU and in-hospital care,” Dr. Piano and colleagues wrote. “Therefore, although survival is excellent, post-transplant care is more complex in patients undergoing LT after a bacterial infection.”

Determining LT Timing After Infection

Historically, it has been unclear how long clinicians should wait before proceeding with LT among those with infections, Dr. Piano and colleagues note.

“An important finding of our study is that, in patients with pre-LT infection, time elapsed from infection improvement/resolution to transplantation did not affect patient outcome. Patients who underwent LT within 7 days [of] infection improvement/resolution had rates of post-operative complications comparable with those of patients who underwent LT beyond 7 days from infection improvement/resolution.”

This finding has direct implications for clinicians, they continue. “As soon as bacterial infection is controlled, it is safe to proceed with LT. This is a novel finding, as no previous study assessed a safe time interval from infection improvement/resolution to LT.”