Invasive fungal disease in patients with end-stage liver disease

Abstract Invasive fungal disease (IFD) has become a critical complication in patients with end-stage liver disease (ESLD), marked by a rising prevalence and the emergence of drug-resistant strains in recent decades. The heightened susceptibility to IFD in ESLD stems from liver-related immune dysfunction, structural changes, and iatrogenic factors, such as invasive procedures, broad-spectrum antibiotics, and immunosuppressive therapies. Timely diagnosis is essential for effective management, yet it remains challenging. This review examines both conventional culture-based and advanced culture-independent diagnostic techniques, including polymerase chain reaction-based assays and the T2Candida Panel. Treatment strategies are stratified according to diagnostic certainty (proven, probable, or possible IFD), although therapeutic efficacy is often limited by antifungal hepatotoxicity and drug resistance. We summarize current treatment recommendations for common IFD pathogens, with an emphasis on pharmacokinetic considerations and dose adjustments in ESLD patients. Given the growing clinical burden of IFD in ESLD, further research is urgently needed to optimize IFD management and prophylaxis in this high-risk population. This review also outlines key priorities for addressing future challenges in diagnosis and therapy.