Infectious Complications in the First Year Post Renal Transplantation

Investigating infectious outcomes in adult patients undergoing solid organ transplantation: A retrospective single-center experience, Paris, France

OBJECTIVES

This study described the demographic characteristics, clinical presentation, treatment, and outcomes of solid organ transplant recipients who were admitted to our center for infection. It also determined factors associated with a poor outcome, and compares early and late period infections.

METHODS

In this retrospective observational study, conducted at a tertiary care center in France between October 2017 and March 2019, infectious outcomes of patients with solid organ transplant where studied.

RESULTS

A total of 104 patients were included with 158 hospitalizations for infection. Among these 104 patients, 71 (68%) were men. The median age was 59 years old. The most common symptoms on admission were fever (66%) and chills (31%). Lower respiratory tract infections were the most common diagnosis (71/158 hospitalizations). Urinary tract infections were frequently seen in kidney transplant recipients (25/60 hospitalizations). One or more infectious agents were isolated for 113 hospitalizations (72%): 70 bacteria, 36 viruses and 10 fungi, with predominance of gram-negative bacilli (53 cases) of which 13 were multidrug-resistant. The most frequently used antibiotics were third generation cephalosporins (40 cases), followed by piperacillin-tazobactam (26 cases). We note that 25 infections (16%) occurred during the first 6 months (early post-transplant period). Patients admitted during the early post-transplant period were more often on immunosuppressive treatment with prednisone (25/25 VS 106/133) (p = 0.01), mycophenolic acid (22/25 VS 86/133) (p = 0.03), presented for an urinary tract infection (10/25 VS 25/133) (p = 0.04) or a bacterial infection (17/25 VS 53/133) (p = 0.01). Patients with later infection had more comorbidities (57/83 VS 9/21) (p = 0.03), cancer (19/83 VS 0/21) (p = 0.04) or were on treatment with everolimus (46/133 VS 0/25) (p = 0.001). During 31 hospitalizations (20%), patients presented with a serious infection requiring intensive care (n = 26; 16%) or leading to death (n = 7; 4%). Bacteremia, pulmonary and cardiac complications were the main risk factors associated with poor outcome.

CONCLUSION

Infections pose a significant challenge in the care of solid organ transplant patients, particularly those with comorbidities and intensive immunosuppression. This underscores the crucial importance of continuous surveillance and epidemiologic monitoring within this patient population.

The Prevalence and Risk Factors for Urinary Tract Infection in Kidney Transplant Recipients in the First Year After Transplantation

Background: End-stage renal disease (ESRD) needs replacement therapy and most often, kidney transplantation is the best therapeutic option. Urinary tract infection (UTI) is one of the most important complications after renal transplantation that affects transplantation outcomes. Objectives: This study aimed to define the incidence rate, UTI risk factors among kidney transplant recipients, and causative organism of UTI and their antibiotic susceptibility. Methods: In this cross-sectional study, we collected clinical, demographic, and laboratory data from 268 transplant recipients in Ali-Asghar Hospital from 2011 - 2018. Data collected from patients were analyzed with SPSS software version 25. Results: According to the results, 50 (18.7%) had UTI in the first year after renal transplantation. Female gender and underlying cause of renal failure were predisposing factors for UTI. The most common causative organism was Escherichia coli (58.4%). The antibiotic susceptibility results showed nitrofurantoin and meropenem as the most effective antibiotics for Escherichia coli. Conclusions: The UTI was more common in women and patients with analgesic nephropathy and lupus nephritis. The most common causative organism was E. coli and meropenem and nitrofurantoin were the most effective drug choices.

Epidemiology, risk factors, and clinical impact of early post-transplant infection in older kidney transplant recipients: the Korean organ transplantation registry study

Background

As in younger recipients, post-transplant infection is a frequent and devastating complication after kidney transplantation (KT) in older recipients. However, few studies have analyzed characteristics of post-transplant infection in older kidney recipients. In this study of a nation-wide cohort of older kidney recipients, we investigated the current epidemiology, risk factors, and clinical impacts of early post-transplant infection, which was defined as infectious complications requiring hospitalization within the first 6 months after KT.

Methods

Three thousand seven hundred thirty-eight kidney recipients registered in the Korean Organ Transplantation Registry between 2014 and 2017 were enrolled. Recipients were divided into two groups, younger (n = 3081) and older (n = 657), with a cutoff age of 60 years. We observed characteristics of early post-transplant infection, and investigated risk factors for the development of infection. We also analyzed the association of early post-transplant infection with clinical outcomes including cardiac events, rejection, graft loss, and all-cause mortality.

Results

The incidence of early post-transplant infection was more frequent in older recipients (16.9% in younger group and 22.7% in older group). Bacteria were the most common causative pathogens of early post-transplant infection, and the most frequent site of infection was the urinary tract in both older and younger recipients. Older recipients experienced more mycobacterial infections, co-infections, and multiple site infections compared with younger recipients. In older recipients, female sex (HR 1.398, 95% CI 1.199–1.631), older donor age (HR 1.010, 95% CI 1.004–1.016), longer hospitalization after KT (HR 1.010, 95% CI 1.006–1.014), and experience of acute rejection (HR 2.907, 95% CI 2.471–3.419) were independent risk factors for the development of early post-transplant infection. Experiencing infection significantly increases the incidence of rejection, graft loss, and all-cause mortality.

Conclusion

Our results illustrate current trends, risk factors, and clinical impacts of early post-transplant infection after KT in older recipients. Considering the poor outcomes associated with early post-transplant infection, careful screening of recipients at high risk for infection and monitoring of recipients who experience infection are advised. In addition, since older recipients exhibit different clinical characteristics than younger recipients, further studies are needed to establish effective strategies for treating older recipients.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12877-020-01859-3.

Five compelling UTI questions after kidney transplant

PURPOSE

Urinary tract infection (UTI) is the most common bacterial infection among infectious complications in kidney transplant recipients (KTR). After transplantation, infections can result from surgical complications, donor-derived infections, pre-existing recipient infections, and nosocomial infections. Post-transplant infection is still a major cause of morbidity, mortality, graft dysfunction and rejection. In this paper, we aimed to review a few compelling questions in kidney transplantation (KTX).

METHODS

To identify relevant clinical questions regarding KTX and UTI a meeting was conducted among physicians involved in the KT program in our hospital. After discussion, several clinically relevant questions related to UTI after KTX. The 5 first rated in importance were judged generalizable to other clinical settings and selected for the purposes of this review.

RESULTS

Nearly half of the patients present in the first three months of transplant with UTI. The most common uropathogens in post-transplant UTIs are Escherichia coli, Klebsiella pneumoniae, and Enterococcus faecalis. Risk factors for UTI include female sex, advanced age, recurrent UTI before transplant, prolonged urethral catheterization, delayed graft function, and cadaveric kidney transplant.

CONCLUSION

The incidence of post-transplant UTI is similar in both developed and developing countries. E.coli is the most common pathogen in most of studies. Cadaveric donor and post-dialysis transplantation are defined as independent risk factors for post-transplant UTI. Further studies are still required to identify risk factors after kidney transplantation and UTI's importance for graft function and patient outcome.

Reoperation in Early Kidney Post-transplant Period as a Strong Risk Factor of Surgical Site Infection Occurrence

BACKGROUND

One of the most common infective complications after kidney transplant (KTx) is surgical site infection (SSI). Providing indications of improvement of perioperative antibiotic prophylaxis (PAP) and allowing the characterization of risk factors are critical to reduce SSI. The purpose of this study was to evaluate the SSI risk factors and impact of reoperation in the early post-transplant period on SSI occurrence and assess if standard PAP in those cases is a best consideration.

METHODS

Between April 2014 and October 2015, a total of 236 KTxs were performed in our center. Deceased donor data, recipient data, and data related to surgical procedures were collected.

RESULTS

Surgical site infections were reported in 5.6% (12/214) of patients. Seven patients were diagnosed as having superficial SSI (7/12; 58.3%), 2 with deep SSI (2/12; 16.6%), and 4 with organ-specific SSI (4/12; 33.3%). Extended criteria donor-related transplant, cold ischemia time > 22 hours, dialysis period > 30 months, recipient age older than 45 years, recipient body mass index > 27, induction therapy prior to transplant, diabetes prior to transplant, and ≥ 1 reoperation during 30 days of observation were independent risk factors of SSI occurrence. A total of 19 reoperations were performed in 17 patients. In 8 of all 12 patients with SSI diagnosis, the reoperation was performed (66.7%). In 202 patients of non-SSI patients, only 9 reoperations were performed (4.5%).

CONCLUSIONS

Early reoperation after Ktx is a strong risk factor of SSI occurrence. There is a probability that > 4 SSI risk factors and reoperation in the early post-transplant period could require different and more aggressive proceeding, as standard PAP in those cases is insufficient.

Infection is the chief cause of mortality and non-death censored graft loss in the first year after renal transplantation in a resource limited population: A single centre study

AIM

Few studies have assessed the impact of infections after renal transplantation (RTX) in low and middle income countries. This single centre study aimed to delineate the profile and impact of infections requiring hospitalization (IRH) occurring in the first year after RTX in India.

METHOD

Patients who underwent RTX between July 2012 and June 2015 were followed up for 12 months after transplantation.

RESULTS

60.2% of the 387 patients studied had at least one IRH and total 492 infections were diagnosed. The most common were urinary tract (30.3%), gastrointestinal (17.1%) and pulmonary (11.2%) infections. Viral aetiology (33.3%) was most frequent, followed by bacterial (23.6%), parasitic (5.1%), tuberculosis (4.5%), and fungal infections (3.9%). 86.4% deaths were due to infections. One year patient and graft survival were inferior among recipients with IRH compared to those with no IRH: 91.8% vs. 98.1% (log rank = 0.010) and 90.1% vs. 97.4% (log rank = 0.006) respectively. Average monthly income per family member <5000 Rupees (75 USD), NODAT, and acute rejection were independent risk factors for IRH.

CONCLUSION

The profile of IRH is unique involving opportunistic, community-acquired and endemic infections seen in this country. It is the predominant cause of mortality and graft loss in the first year after RTX. Poor economic status is an important determinant of IRH in our population.

Epidemiology, susceptibility, and risk factors for acquisition of MDR/XDR Gram-negative bacteria among kidney transplant recipients with urinary tract infections

Background

Multiple drug resistant/extensively drug resistant (MDR/XDR) Gram-negative urinary tract infections (UTIs) represent a growing threat to kidney transplant recipients. This retrospective study aimed to assess the incidence and microbiological profile of MDR/XDR Gram-negative UTIs, to identify drug susceptibility of MDR/XDR bacteria, and to determine the potential risk factors for MDR/XDR UTIs in kidney recipients.

Materials and methods

During the study period, 1569 patients underwent consecutive kidney transplantation in two transplantation centers. We studied the demographics, clinical characteristics, and urine culture data from kidney recipients with MDR/XDR Gram-negative UTIs, and verified the risk factors associated with MDR/XDR infections.

Results

Eighty-one kidney recipients yielded 88 episodes of MDR/XDR Gram-negative UTIs with five patients (6.2%) succumbing to all-cause in-hospital mortality. The most frequently isolated bacterium was Escherichia coli (62.5%). Almost all MDR/XDR Gram-negative bacteria were resistant to first- and second-generation cephalosporin, and monocyclic beta-lactam. They were relatively sensitive to meropenem, amikacin, and tigecycline. As for the 12 XDR bacteria, all of them were resistant to meropenem and 25% of them were resistant to tigecycline. All XDR Acinetobacter baumannii and E. coli were susceptible to tigecycline. Nosocomial infection (odds ratio [OR] = 11.429, 95% CI = 1.311–99.625, P = 0.027) was the only independent predictor of MDR/XDR Gram-negative UTIs. Non-fermenting bacterial infection (OR = 20.161, 95% CI = 3.409–119.240, P = 0.001), polycystic kidney disease (OR = 39.871, 95% CI = 1.979–803.384, P = 0.016), and serum creatinine level > 1.5 mg/dL (OR = 8.688, 95% CI = 1.354–55.747, P = 0.023) were significantly different between XDR and MDR Gram-negative UTIs.

Conclusion

Meropenem, amikacin, and/or tigecycline can be prescribed for MDR/XDR Gram-negative infections. Tigecycline can also be prescribed for XDR A. baumannii and E. coli. Nosocomial infection was a risk factor for MDR/XDR Gram-negative UTIs, while XDR UTIs were associated with non-fermenting bacterial infection, polycystic kidney disease, and impaired renal function.

Safety and Efficacy of Induction Therapy With Thymoglobulin in AB0-Incompatible Kidney Transplantation

INTRODUCTION

Data suggest an additional role of T cells in antibody-mediated rejections. In 2001 a protocol for AB0-incompatible kidney transplantation based on B-cell-depleting anti-CD20 antibody rituximab, antigen-specific blood group IgG immunoadsorption, intravenous immunoglobulins, and triple immunosuppression was introduced in Europe, which used induction therapy with the use of interleukin-2 receptor antibody (IL2-RA) basiliximab. We used thymoglobulin in AB0-incompatible patients as induction in the face of high immunologic risk.

METHODS

We retrospectively evaluated a cohort of 9 AB0i living donation (LD) recipients from 2011 to 2014. Desensitization included blood group-specific immunoadsorption. Eighteen AB0-compatible LD recipients receiving induction therapy with thymoglobulin served as control subjects. Another control group consisted of 18 AB0-compatible LD recipients receiving basiliximab. Follow-up was 24 months. We captured graft function by estimating glomerular filtration rate (eGFR by Modification of Diet in Renal Disease formula), rejection episodes, and bacterial and viral infections.

RESULTS

All patients experienced immediate graft function. No significant or clinical differences were observed regarding graft function, rejection rates, or infections between the groups, although there seemed to be slightly higher cytomegalovirus infection rates due to preemptive therapy strategy.

CONCLUSIONS

Thymoglobulin appears to be similar in safety and efficacy to IL-2-antagonists in AB0i kidney transplantation.

Epidemiology of Infectious Complications in Renal Allograft Recipients in the First Year After Transplant

OBJECTIVES

Renal transplant is one of the best ways to extend life of patients in the end stage of renal disease. Infections are significant causes of morbidity and mortality after renal transplant. The aim of this study was to evaluate frequency, risk factors, causative pathogens, and clinical manifestations in renal transplant recipients from Mashhad City during the first year after transplant.

MATERIALS AND METHODS

This research was conducted at Montaserie Hospital of Mashhad University of Medical Sciences from March 2013 to July 2015. All studied cases were followed for 1 year. In this retrospective study, our study cohort comprised 193 kidney transplant recipients, including 118 male (61.1%) and 75 female (38.9%) patients, with mean age of 34.4 ± 12.2 years. Of the total patients, 58 received kidneys from living donors (30.1%) and 135 received kidneys from deceased donors (69.9%).

RESULTS

We found that 151 infectious episodes had occurred in 96 patients. The most common infectious site involved the urinary tract (39.1%). Escherichia coli was the most frequently isolated pathogen. The only significant infection risk factor to affect transplant outcomes during the first year was age.

CONCLUSIONS

Infections are highly prevalent during the first year after transplant. Prevention and effective antibiotic therapy can reduce the related adverse effects.

Early Infections in Renal Transplant Recipients: Incidence, Risk Factors, and Causative Microorganisms

OBJECTIVES

This study aimed to compare renal transplant recipients with and without infection with respect to demographic and clinical characteristics as well as risk factors; to determine the incidence of posttransplant infections; and to study the antibiotic resistance patterns of bacterial species identified as the causative organisms in posttransplant infections.

MATERIALS AND METHODS

This study included a total of 136 patients undergoing renal transplant in a 4-year period. The patients were categorized into 2 groups. The 2 groups were compared with each other with respect to general clinical and demographic variables and the number and frequency of infectious attacks within a 1-year follow-up, infection type, and antibiotic resistance patterns.

RESULTS

Ninety-two (67.6%) of the subjects were male and 44 (32.4%) were female. A total of 57 (41.9%) patients developed 128 infectious attacks. Urinary tract infections were the most common infections (42.1%). There was a significant correlation between a clinically relevant urinary culture proliferation and postoperative infection rate (P = .002). There was a significant correlation between antimicrobial resistance and the number of infectious attacks (P = .023). There was a significant correlation between the proliferation of Extended Spectrum Beta Lactamase-positive Enterobactericeae species and the number of infectious attacks (P = .000).

CONCLUSIONS

Presence of a clinically relevant proliferation in the preoperative urinary culture, which was identified as a risk factor for infection, increased the number of infectious attacks. Moreover, Extended Spectrum Beta Lactamase-positive Enterobactericeae species increased the number of infections. These 2 principle results should be taken into account in patient management.

Study of intercurrent infection pattern in hepatitis C seropositive renal transplant recipients, relationship with T-cell function

BACKGROUND

We assessed the effect of hepatitis C seropositivity on the percentage of various T-cells in living donor renal transplant recipients (LDRTRs) and their association with intercurrent infections post renal transplantation (post-Tx).

METHODS

One hundred and thirty-three matching LDRTRs [A (seronegative) (68 patients) and B (seropositive) (65 patients) by ELISA] were studied prospectively 10 days, 6 months and 12 months post-Tx for intercurrent infections, acute rejection and T-cell% by flow cytometry.

RESULTS

CD4(+), CD8(+), CD4/CD8 were significantly higher 10 days post-Tx in Group B compared to Group A, p < 0.001. A significant increase in CD8% was seen 6-month post-Tx among Group B compared to Group A. No difference was detected between groups in (CD4(+), CD8(+), CD4/CD8, CD3-CD16/65(+)%), rate and severity of intercurrent infection, rate of acute rejection, 12 months post-Tx. A significantly higher rate of severe infections particularly urinary tract infections (UTI) was noted in Group B compared to Group A the first 3 months post-Tx particularly in those who received the combination of antithymocyte globulin (ATG) or basiliximab, tacrolimus, steroids, mycophenolate mofetil (MMF). CD4(+)% correlated negatively with intercurrent infections in Group B 6 months post-Tx.

CONCLUSION

HCV(+) patients are more prone to intercurrent infections the first 3 months post-Tx. Infection rate correlates positively with pre-transplant HCV seropositivity and immunosuppressive regimen.

Clinical and microbiological epidemiology of early and late infectious complications among solid-organ transplant recipients requiring hospitalization

There is limited literature describing the clinical and microbiological characteristics of solid-organ transplant recipients requiring hospitalization for infectious complications. This study reports on the rate and timing of these syndromes and describes the associated microbiological epidemiology. This prevalence cohort study evaluated solid-organ transplant recipients requiring hospitalization during 2007-2011. We reported infectious complications requiring hospitalization in 603 of 1414 readmissions at a rate of 0.43 episodes per 1000 transplant-days (95% CI, 0.40-0.47), with 85% occurring >6 months post-transplantation. The most frequent infectious complications were as follows: respiratory (27%), sepsis or bacteremia (13%), liver or biliary tract (12%), genitourinary (12%), and cytomegalovirus related (9%). Approximately 53% presented without fever, 45% had no pathogen isolated, and multidrug-resistant organisms were isolated in 27% of those with an identified microbiological etiology. Infectious-related complications continue to pose a high clinical burden on our acute care center, with the majority occurring in the late transplant period. Clinicians are faced with the difficult task of prescribing adequate antimicrobial therapy.

Prevalence and genotype distribution of cytomegalovirus UL55 sequence in renal transplant recipients in north west of Iran

Cytomegalovirus (CMV) is one of the most important infections in renal transplant recipients. Kidney transplant is the last hope for the patients with end stage renal diseases. Cytomegalovirus infection can threaten patients and graft survival after transplantation. Four hundred and thirty-four renal transplant recipients contributed to this study. PCR and RFLP analyses were performed in order to determine CMV viremia and its genotypes. CMV viremia was detected in 68 (15.9%) recipients. The mean post-transplantation time in our recipients was 50 months, ranging from 1 to 354 months. Viremia was detected in 31.2%, 30.7%, 17.5%, 10.2%, and 6.4% of the recipients in 0-3, 4-6, 7-12, 13-24, and more than 24 months post-transplantation, respectively. The distribution of gB1, gB2, gB3, and gB4 genotypes was detected as 26.5%, 20.5%, 17.6%, and 5.9%, respectively. Mixed genotype infection was observed in 29.4% of the recipients. Incidence of viremia was higher in the first 6 months after the transplantation compared with the later stages. Moreover, CMV gB1 and mixed genotype infection were more common in our recipients. J. Med. Virol. 88:1622-1627, 2016. © 2016 Wiley Periodicals, Inc.

Evaluation of Infectious Complications in the First Year After Kidney Transplantation

Kidney transplantation (KT) is the best available therapy for patients with end-stage renal disease. Infectious complications are a common cause of morbidity and mortality. In this study, we evaluated the risk factors and outcomes of infectious complications in the first year after transplantation. This is a retrospective and observational study of kidney transplant recipients at Ankara University's Ibni Sina Hospital between January 2009 and August 2013. A total of 206 kidney transplant recipients were evaluated. In 129 patients, 298 infectious episodes occurred: 55 (26.7%) had 1; 33 (16%) 2; 19 (9.2%) 3; 7 (3.4%) 4; and 15 (7.3%) had 5 or more infectious episodes. The most common bacterial infection was urinary tract infection (128, 42.9%). Only 4 urinary tract infection episodes (3.1%) were associated with bacteriemia. Seventeen patients (5.7%) had bacteremia. Viral infections after transplantation were CMV infection (10.1%), BK virus infection (5.7%), and zona zoster (1.1%). Deceased donor kidney transplantation was the independent risk factor. Mean follow-up period was 66 months and was the same for the patients with and without infections. There was no significant difference in 5-year survival and creatinine levels at the last follow-up (logrank P = .409). Infections are the second most common cause of mortality in KT patients. The successful treatment of these complications and effective prophylaxis may decrease these complications.

Study of the risk factors related to acquisition of urinary tract infections in patients submitted to renal transplant

INTRODUCTION

Urinary tract infections (UTI) among transplant recipients are usually caused by gram-negative microorganisms and can provoke a high incidence of morbidity and mortality. The aim of this study was to evaluate the risk factors associated with the acquisition of UTIs during the first year after renal transplantation.

METHODS

Here, we report a single-center retrospective cohort study of 99 renal transplant patients followed for the first year after surgery. The definition of a UTI episode was a urine culture showing bacterial growth and leucocyturia when patients presented with urinary symptoms. The absence of infection (asymptomatic bacteriuria) was defined as an absence of symptoms with negative urine culture or bacterial growth with any number of colonies.

RESULTS

Ninety-nine patients were included in the study. During the study, 1,847 urine cultures were collected, and 320 (17.3%) tested positive for bacterial growth. Twenty-six (26.2%) patients developed a UTI. The most frequent microorganisms isolated from patients with UTIs were Klebsiella pneumoniae (36%), with 33% of the strains resistant to carbapenems, followed by Escherichia coli (20%). There were no deaths or graft losses associated with UTI episodes.

CONCLUSIONS

Among the UTI risk factors studied, the only one that was associated with a higher incidence of infection was female sex. Moreover, the identification of drug-resistant strains is worrisome, as these infections have become widespread globally and represent a challenge in the control and management of infections, especially in solid organ transplantation.

Infection-related hospitalizations over 30 years of follow-up in patients starting renal replacement therapy at pediatric age

BACKGROUND

Pediatric renal replacement therapy (RRT) patients surviving long-term are at a much higher risk of mortality compared with the age-matched general population. Recently, we demonstrated a transition from cardiovascular disease to infection as the main cause of death in a long-term follow-up study of pediatric RRT. Here, we explore the burden of infections requiring hospitalization over 30 years of follow-up on RRT.

METHODS

The cohort comprised all 234 Dutch patients on RRT under 15 years of age between 1972 and 1992. We analyzed infection-related hospitalizations during the period 1980–2010. We evaluated the Hospital Admission Rate (HAR) per patient-years (py) and infectious over noninfectious HAR ratio (HARR).

RESULTS

The HAR decreased significantly over time for all patients. The rate of hemodialysis-related infections decreased between 1980 and 1999, but stabilized during 2000–2010, whereas peritoneal dialysis-related infections decreased progressively. Transplantation-related infections did not change, except for urinary tract infections (UTIs), which increased significantly from 3.3/100 py [95%CI 3.2–3.4] in 1980–1989 to 4.4/100 py [4.2–4.5] in 2000–2010 (p <0.001). The contribution of infection to HAR increased significantly in transplanted patients (HARR: 1980–1989: 0.25 [0.2–0.3]; 2000–2010: 1.0 [0.79–1.27], p <0.001).

CONCLUSIONS

Our findings indicate a relative increase in infections requiring hospitalization over time in patients starting RRT during the pediatric age, especially severe UTIs in transplantation. More attention paid to urological abnormalities in cases of recurrent UTI and tailored adjustment of immunosuppression may reduce risk in these patients.

Clinical and economic consequences of first-year urinary tract infections, sepsis, and pneumonia in contemporary kidney transplantation practice

We examined United States Renal Data System registry records for Medicare-insured kidney transplant recipients in 2000-2011 to study the clinical and cost impacts of urinary tract infections (UTI), pneumonia, and sepsis in the first year post-transplant among a contemporary, national cohort. Infections were identified by billing diagnostic codes. Among 60 702 recipients, 45% experienced at least one study infection in the first year post-transplant, including UTI in 32%, pneumonia in 13%, and sepsis in 12%. Older recipient age, female sex, diabetic kidney failure, nonstandard criteria organs, sirolimus-based immunosuppression, and steroids at discharge were associated with increased risk of first-year infections. By time-varying, multivariate Cox regression, all study infections predicted increased first-year mortality, ranging from 41% (aHR 1.41, 95% CI 1.25-1.56) for UTI alone, 6- to 12-fold risk for pneumonia or sepsis alone, to 34-fold risk (aHR 34.38, 95% CI 30.35-38.95) for those with all three infections. Infections also significantly increased first-year costs, from $17 691 (standard error (SE) $591) marginal cost increase for UTI alone, to approximately $40 000-$50 000 (SE $1054-1238) for pneumonia or sepsis alone, to $134 773 (SE $1876) for those with UTI, pneumonia, and sepsis. Clinical and economic impacts persisted in years 2-3 post-transplant. Early infections reflect important targets for management protocols to improve post-transplant outcomes and reduce costs of care.

Predictive factors of infection in the first year after kidney transplantation

BACKGROUND

Infectious disease, a complication favored by immunosuppression, is the main cause of 1st-year mortality in solid organ transplantation. In renal transplant recipients (RTRs), urinary tract infection (UTI) is the most common, and the microorganisms that are isolated depend on chronology.

METHODS

We present an observational study comprising 129 RTRs from January 2010 to December 2011 who were followed during the 1st year after transplantation. We analyzed occurrence of infections, predisposing factors, timing, severity, site of infection, and microorganisms.

RESULTS

The patients had a total of 424 infectious episodes during the 1st year (3.29 episodes/patient/year). The predominant focus was the urinary tract, with at least 1 episode in 69.8% of patients. Bacteremia was recorded in 25.6% of patients and surgical wound infection in 20.9%. Cytomegalovirus infection or disease was diagnosed in 46.5%. Severe infections occurred in 30.2%. The predominant pathogen was E. coli. There was a significant correlation between hospital stay and the number of infections (P = .000; r = 0.407) and between body mass index and hospital stay (P = .001; r = 0.282). Severe infections were more frequent in diabetics, patients with a double-J stent, and those treated with basiliximab. Patients with cytomegalovirus replication had a higher number of infections (4.1 ± 1.2 vs 2.5 ± 5; P = .000) and significantly higher annual serum creatinine (1.65 ± 5.7 vs 1.31 ± 1.3 mg/dL; P = .003).

CONCLUSIONS

The prevalence of infections in the 1st year after kidney transplantation is very high, occurring mainly in the early period, in the urinary tract, and due to E. coli. Cytomegalovirus replication is associated with a higher number of infections and higher serum creatinine at 1 year. Body mass index is a predictor of early infection and of bacteremia in the post-transplantation period. Basiliximab induction and having a double-J stent were predictors of severe infections.