Epidemiology and Outcomes of Cryptococcal Infections in Liver Transplant Recipients: A Retrospective Cohort Study at a US Academic Center

Rachel Sigler; Chloe Hanigan; Atikur Rahman; Isuru Ratnayake; Phani Akella; Lauren Carlini; Chelsea Gorsline; Erica Mackenzie; Albert Eid; Dennis Shoemaker; Ryan Taylor; Stephen Waller

doi:10.1111/tid.70231

Epidemiology and Outcomes of Cryptococcal Infections in Liver Transplant Recipients: A Retrospective Cohort Study at a US Academic Center

Transpl Infect Dis. 2026 May 6:e70231. doi: 10.1111/tid.70231. Online ahead of print.

Authors

Affiliations

¹ Division of Infectious Diseases, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA.
² School of Medicine, University of Kansas, Kansas City, Kansas, USA.
³ Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA.
⁴ Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA.

PMID: 42093238
DOI: 10.1111/tid.70231

Abstract

Background: Cryptococcal infections in solid organ transplant (SOT) are relatively uncommon posttransplant, but carry significant morbidity and mortality. SOT represents a significant proportion of cryptococcosis among immunocompromised patients. Data specific to liver transplant recipients remains limited.

Methods: We performed a retrospective cohort study of 346 liver transplant recipients at a US academic center to identify predictors and outcomes associated with cryptococcal infection. Associations between infection and clinical variables were analyzed. Univariate logistic regression was performed to estimate odds ratios (OR) and 95% confidence intervals (CI).

Results: Twelve patients (3.6%) developed cryptococcosis within 1 year of liver transplant. Significant differences between infected and noninfected patients were observed for maintenance immunosuppression (p < 0.001), infectious comorbidities (p = 0.007), and treatment of rejection (p = 0.041). Patients residing in rural ZIP codes had a significantly higher risk of cryptococcal infection, whereas residing in urban ZIP codes was found to be protective (OR 0.305; 95% CI 0.095-0.985; p = 0.047). Longer waitlist duration also increased infection risk at 0.01% per day (p = 0.017). Among infected patients, very early infection (< 45 days posttransplant) was associated with shorter median survival (382 days) compared with early (45-180 days posttransplant, median1462 days survival) and late (> 180 days posttransplant, median 1641 days survival) infection (p = 0.09).

Conclusions: Cryptococcal infection after liver transplantation is rare but linked to immunosuppression patterns and geographic risk factors. Recipients from rural ZIP codes may face increased environmental exposure or healthcare access barriers, contributing to elevated risk. Multicenter studies are warranted to identify modifiable risk factors and guide antifungal prophylaxis and screening strategies.

Keywords: cryptococcus; fungal infection; immunosuppression; liver transplantation; rural health.