Predicting VRE Infection After Liver Transplantation With a Time-Updated Colonization Score

Vancomycin-resistant Enterococcus (VRE) infection is a life-threatening complication after liver transplantation (LT). This study aimed to identify risk factors and develop a predictive score for post-transplant VRE infection in LT recipients.

We conducted a single-center, retrospective cohort study including all adult patients who underwent LT between 2010 and 2022. Patients were followed from 90 days before to 180 days after LT. The primary endpoint was time to the first VRE infection after LT, with death before infection treated as a competing event. We applied a stacked landmarking approach at weekly intervals during the first post-transplant month, incorporating post-LT VRE colonization as a time-dependent covariate in Fine-Gray models. Random forests were used as machine-learning comparators. Model discrimination was assessed by the AUC-ROC, and sensitivity, specificity, and accuracy were calculated at thresholds determined by Youden's index.

Among 1209 LT recipients, 76 (6.3%) developed VRE infection, most commonly intra-abdominal (58.4%). Time-updated post-LT VRE colonization was the strongest predictor (HR 7.59). Additional risk factors included intraoperative bleeding (HR 4.06), early re-transplantation (HR 3.85), pre-LT VRE colonization (HR 3.20), renal replacement therapy (HR 2.01), and intensive care unit length of stay (HR 1.01/day). Viral hepatitis (HR 0.55), autoimmune hepatitis (HR 0.34), higher Charlson Comorbidity Index (HR 0.84), and deceased donors (HR 0.24) were associated with a lower risk of VRE infection. The final model showed good discrimination (AUROC = 0.76-0.85) with balanced sensitivity (75%-93%) and specificity (75%-86%).