Clinical Approach to the Management of Infections before and after Liver Transplantation

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The infectious complications before and after liver transplant (LT) are affected by the severity of liver disease and immunosuppression intensity after transplantation. Both cirrhosis and immunosuppression contribute to dysfunction of defensive mechanisms of the host. When a patient is evaluated for transplantation, the opportunity arises to assess the individual’s risk for infection and how one may modify those risks through prophylactic and therapeutic strategies. Pretransplant infectious disease evaluation focuses on exposure history, prior infections, serologic testing for latent infections, distant exposures, identify colonization patterns of MDRO, and administration of vaccines. The risk of acquiring rare infections are increasing because of greater global mobility. Additional evaluation should be considered for some endemic infectious diseases, beyond recommended standard testing for transplant candidates and donors. It is important to have knowledge of risk factors, local epidemiology and resistance pattern of organisms for management of infections in post-transplant period. Infections are often recipient or donor derived or can be associated with surgical and nosocomial complications during 1st month after LT. Opportunistic infections are common during first year after transplantation due to higher intensty of immunosuppression, while the risk goes down with time but is never zero as intermittent augmentation of immunosuppression can bring the risk back. The risk factors for infection after LT is both donor and recipient derived, as well as aspects related to the transplant operation. In recent studies genetic polymorphisms in the innate immune system , from both donor and recipient, have been identified as important risk factor for infection after LT. Early diagnosis of infections using advanced diagnostic approaches, closer surveillance and targeted treatment protocols are required to manage infectious complications in LTR. Rigorous screening of both donor and recipient for latent and active infections is essential for best outcome after liver transplantation. Most of the liver transplant centers have dedicated physicians with expertise in transplant infectious disease and it is advisable if these experts are consulted when the patients admitted to non transplant centers.