Clinical and microbiological risk factors associated with histopathological fungal infection in liver transplant explants: a retrospective cohort analysis

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Background: Liver transplantation is the definitive treatment for end-stage liver disease; however, chronic graft failure remains a significant clinical challenge. Invasive fungal infections (IFIs) are increasingly being recognized as contributors to reduced patient survival. Aims: This study aimed to evaluate the clinical and microbiological risk factors associated with histopathologically confirmed biliary IFIs in explanted liver grafts. Methods: In this retrospective cohort study, 144 transplantations performed between 1990 and 2019 in 132 patients were analyzed. Patients were stratified into two groups based on the presence (n = 41) or absence (n = 103) of histopathologically confirmed biliary IFI. Clinical data, operative parameters, and postoperative complications were extracted, and microbiological cultures of bile and abscess fluid were reviewed. Survival outcomes were assessed using Kaplan–Meier analysis, and independent risk factors were identified using multivariate logistic regression. Results: IFI was detected in 28.5% of explanted livers. Patients with IFI exhibited significantly higher rates of ischemia-type biliary lesions (90.2% vs. 41.8%, p<0.001) and hepatic artery thrombosis (51.2% vs. 16.5%, p<0.001) than those in the non-IFI group. Longitudinal fungal cultures from the bile and abscess fluid were more frequently positive in the IFI group (84.9% and 77.8%, respectively) than in the non-IFI group (63.8% (p=0.033) and 37.5% (p=0.017), respectively). Survival analysis demonstrated markedly reduced outcomes in the IFI group, with median patient survival of 2.9 years versus 11.8 years (Gehan-Breslow-Wilcoxon test p=0.0087) and median organ survival of 1.4 years versus 3.5 years (Gehan-Breslow-Wilcoxon test p=0.0062). Multivariate analysis identified non-anastomotic biliary lesions (odds ratio [OR] = 9.9) and hepatic artery thrombosis (OR = 3.4) as independent predictors of IFI. Conclusion: Histopathologically confirmed biliary IFI in liver transplant recipients is associated with ischemia-type biliary lesions, arterial thrombosis, and markedly reduced survival. The fungal positivity rate of bile and abscess fluid cultures is significantly associated with biliary IFI. Further microbiological studies are warranted to improve early diagnosis. Publication History Article published online: 04 September 2025 © 2025. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

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