Invasive aspergillosis in solid organ transplant patients: diagnosis, prophylaxis, treatment, and assessment of response

Jörg Janne Vehreschild,Christoph Lichtenstern,Carolina Garcia-Vidal,Frédéric Lamoth,Dionysios Neofytos,Alessandro Perrella

doi:10.1186/s12879-021-05958-3

Abstract

BackgroundInvasive aspergillosis (IA) is a rare complication in solid organ transplant (SOT) recipients. Although IA has significant implications on graft and patient survival, data on diagnosis and management of this infection in SOT recipients are still limited.MethodsDiscussion of current practices and limitations in the diagnosis, prophylaxis, and treatment of IA and proposal of means of assessing treatment response in SOT recipients.ResultsLiver, lung, heart or kidney transplant recipients have common as well as different risk factors to the development of IA, thus each category needs a separate evaluation. Diagnosis of IA in SOT recipients requires a high degree of awareness, because established diagnostic tools may not provide the same sensitivity and specificity observed in the neutropenic population. IA treatment relies primarily on mold-active triazoles, but potential interactions with immunosuppressants and other concomitant therapies need special attention.ConclusionsCriteria to assess response have not been sufficiently evaluated in the SOT population and CT lesion dynamics, and serologic markers may be influenced by the underlying disease and type and severity of immunosuppression. There is a need for well-orchestrated efforts to study IA diagnosis and management in SOT recipients and to develop comprehensive guidelines for this population.

Highlights

Invasive aspergillosis (IA) is a rare complication in solid organ transplant (SOT) recipients
Lack of prospective high-quality clinical studies on the performance of imaging, microbiology, and/or laboratory biomarkers for the diagnosis of IA in SOT recipients significantly limits our ability to establish a definitive diagnosis of IA in SOT setting and requires additional efforts to optimize the use of these tools
Diagnosis of IA in SOT recipients requires a high degree of clinical suspicion and awareness, especially because established diagnostic tools, such as the GM Galactomannan enzyme immunoassay (EIA) test and Computerised tomography (CT), do not provide the same sensitivity and specificity observed in the neutropenic population

Summary

Introduction

Invasive aspergillosis (IA) is a rare complication in solid organ transplant (SOT) recipients. Invasive mold infections (IMI), in particular invasive aspergillosis (IA), are a relatively rare complication in solid organ transplant (SOT) recipients [1–3], albeit associated with high rates of graft loss and mortality [4]. The overall incidence of IA among SOT recipients remains below 10% and varies depending on the organ transplanted [1, 5]. Considering the devastating consequences of IA in SOT recipients [3, 5], mold-active primary prophylaxis is used routinely in some transplant centers [10]. The administration of broad-spectrum antifungal prophylaxis in the SOT setting remains controversial, considering the lack of available evidence, significant drug-drug interactions ( between azoles and some immunosuppressive agents), costs, selection for resistant pathogens (in particular, Candida spp.) and the risk of breakthrough IMI caused by resistant molds [11]. The pathophysiology of IA and the effects of the intensity and duration of immunosuppressive therapy on IA are better appreciated [5], a large array of additional risk factors appear to be of variable importance for different transplanted organs (Table 2)

Methods

Results

Conclusion