CAQ Corner: Infections in liver transplant recipients

Infections cause substantial complications after liver transplantation (LT) and increase the risk of mortality. In this review, we will discuss donor-derived infections (DDIs) and opportunistic infections (OIs) after LT. Most DDIs are expected (either from viral hepatitis or known donor infection), while unexpected DDIs are rare. OIs are common, especially so within the first six months after LT when the recipient is the most immunosuppressed. Cytomegalovirus (CMV) is a common post-transplant infection in LT recipients. Recipients who are high-risk for CMV infection are either started on prophylaxis or pre-emptively monitored. Other OIs caused by viruses include Epstein Barr virus, Hepatitis E virus, and SARS-CoV-2. Fungal infections are OIs that carry the highest post-LT mortality rates. Recipients who are older, received broad-spectrum antibiotics, had recent viral infections like CMV, received renal replacement therapy, or had a hepaticojejunostomy are at higher risk. Finally, tuberculosis can reactivate post-LT and cause significant morbidity and mortality. Pre-LT testing is often unreliable in patients with cirrhosis so a high index of suspicion must be maintained in those from endemic areas. In conclusion, DDIs and OIs are common and are associated with morbidity and mortality if not appropriately diagnosed and treated.