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Cheng B, Qi C, Zhang S, Wang X. Risk factors for Pneumocystis jirovecii pneumonia after kidney transplantation: A systematic review and meta-analysis. Clin Transplant 2024; 38:e15320. [PMID: 38690617 DOI: 10.1111/ctr.15320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 04/02/2024] [Accepted: 04/08/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND AND OBJECTIVE Pneumocystis jirovecii pneumonia (PJP), an opportunistic infection, often leads to an increase in hospitalization time and mortality rates in kidney transplant (KT) recipients. However, the risk factors associated with PJP in KT recipients remain debatable. Therefore, we conducted this meta-analysis to identify risk factors for PJP, which could potentially help to reduce PJP incidence and improve outcome of KT recipients. METHODS We systematically retrieved relevant studies in PubMed, EMBASE, and the Cochrane Library up to November 2023. Pooled odds ratios (ORs) or mean differences (MDs) and the corresponding 95% confidence intervals (CIs) were calculated to assess the impact of potential risk factors on the occurrence of PJP. RESULTS 27 studies including 42383 KT recipients were included. In this meta-analysis, age at transplantation (MD = 3.48; 95% CI = .56-6.41; p = .02), cytomegalovirus (CMV) infection (OR = 4.00; 95% CI = 2.53-6.32; p = .001), BK viremia (OR = 3.38; 95% CI = 1.70-6.71; p = .001), acute rejection (OR = 3.66; 95% CI = 2.44-5.49; p = .001), ABO-incompatibility (OR = 2.51; 95% CI = 1.57-4.01; p = .001), estimated glomerular filtration rate (eGFR) (MD = -14.52; 95% CI = -25.37- (-3.67); p = .009), lymphocyte count (MD = -.54; 95% CI = -.92- (-.16); p = .006) and anti-PJP prophylaxis (OR = .53; 95% CI = .28-.98; p = .04) were significantly associated with PJP occurrence. CONCLUSION Our findings suggest that transplantation age greater than 50 years old, CMV infection, BK viremia, acute rejection, ABO-incompatibility, decreased eGFR and lymphopenia were risk factors for PJP.
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Affiliation(s)
- Bingjie Cheng
- Department of Nephrology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chang Qi
- Department of Nephrology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Senlin Zhang
- Department of Hematology and Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Xiaowen Wang
- Department of Nephrology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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2
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Chen RY, Li DW, Wang JY, Zhuang SY, Wu HY, Wu JJ, Qu JW, Sun N, Zhong C, Zhu C, Zhang M, Yu YT, Yuan XD. Prophylactic effect of low-dose trimethoprim-sulfamethoxazole for Pneumocystis jirovecii pneumonia in adult recipients of kidney transplantation: a real-world data study. Int J Infect Dis 2022; 125:209-215. [PMID: 36243280 DOI: 10.1016/j.ijid.2022.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/26/2022] [Accepted: 10/03/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To evaluate the efficacy and safety of low-dose trimethoprim (TMP)-sulfamethoxazole (SMX) (TMP-SMX) as the primary prophylaxis for Pneumocystis jirovecii pneumonia (PJP) in adult recipients of kidney transplantation. METHODS Three kinds of prescriptions in kidney recipients were documented, including 20 mg TMP/100 mg SMX oral daily, 20 mg TMP/100 mg SMX oral every other day, and nonprophylaxis. The primary outcome was the incidence of PJP in the first 180 days of follow-up after kidney transplantation. The secondary outcomes were changes in renal and liver function. RESULTS Among the 1469 recipients, 1066 (72.56%) received 20 mg TMP/100 mg SMX daily, 127 (8.65%) received 20 mg TMP/100 mg SMX every other day, and 276 (18.79%) did not have prophylaxis prescription. The 276 recipients in the nonprophylaxis group had 124.92 person-years of follow-up, during which PJP occurred in 29 patients, for an incidence rate of 23.21 (95% confidence interval 15.76-32.72) per 100 person-years. The TMP-SMX daily group and the TMP-SMX every other day group had 524.89 and 62.07 person-years of follow-up, respectively, with no occurrence of PJP. There was no significant difference among the three groups in changes in renal and liver function (P >0.05, respectively). A total of 111 recipients in each group were enrolled in the propensity score matching analysis. It was revealed that the 111 nonprophylaxis recipients had 51.27 person-years of follow-up and 10 PJP cases. Prophylaxis was considered effective because there was a significant difference between the three groups (P <0.001). CONCLUSION Low-dose TMP-SMX prophylaxis significantly reduces the incidence of PJP within 6 months after kidney transplantation and has a favorable safety profile.
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Affiliation(s)
- Ruo-Yang Chen
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Da-Wei Li
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jie-Ying Wang
- Department of Clinical Research Center, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Shao-Yong Zhuang
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Hao-Yu Wu
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jia-Jin Wu
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jun-Wen Qu
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Nan Sun
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Chen Zhong
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Cheng Zhu
- Department of Disease Prevention and Control, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Ming Zhang
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.
| | - Yue-Tian Yu
- Department of Critical Care Medicine, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.
| | - Xiao-Dong Yuan
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.
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Sommerer C, Schröter I, Gruneberg K, Schindler D, Behnisch R, Morath C, Renders L, Heemann U, Schnitzler P, Melk A, Della Penna A, Nadalin S, Heeg K, Meuer S, Zeier M, Giese T. Incidences of infectious events in a renal transplant cohort of the German Center of Infectious Diseases (DZIF). Open Forum Infect Dis 2022; 9:ofac243. [PMID: 35855001 PMCID: PMC9280327 DOI: 10.1093/ofid/ofac243] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/11/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Infectious complications are a major cause of morbidity and mortality after kidney transplantation.
Methods
In this transplant cohort study at the German Center of Infectious Diseases (DZIF), we evaluated all infections occurring during the first year after renal transplantation. We assessed microbial etiology, incidence rates, and temporal occurrence of these infections.
Results
Of 804 renal transplant recipients (65.2% male, 51 ± 14 years), 439 (54.6%) had 972 infections within the first year after transplantation. Almost half of these infections (47.8%) occurred within the first three months. Bacteria were responsible for 66.4% (645/972) of all infections, followed by viral (28.9%[281/972]) and fungal (4.7%[46/972]) pathogens. The urinary tract was the most common site of infection (42.4%). Enterococcus was most frequently isolated bacteria (20.9%), followed by E.coli (17.6%) and Klebsiella (12.5%). E.coli was the leading pathogen in recipients <50 years of age, whereas Enterococcus predominated in older recipients. Resistant bacteria were responsible for at least one infection in 9.5% (76/804) of all recipients. Viral infections occurred in 201 recipients (25.0%). Of these, herpes viruses predominated (140/281[49.8%]) and cytomegalovirus had the highest incidence rate (12.3%). In the 46 fungal infections, Candida albicans (40.8%) was most commonly isolated. Other fungal opportunistic pathogens, including Aspergillus fumigatus and Pneumocystis, were rare.
Conclusions
Renal allograft recipients in Germany experience a high burden of infectious complications in the first year after transplantation. Bacteria were the predominating pathogen, followed by opportunistic infections such as cytomegalovirus. Microbial etiology varied between age groups and resistant bacteria were identified in 10% of recipients.
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Affiliation(s)
- Claudia Sommerer
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Iris Schröter
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Katrin Gruneberg
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Daniela Schindler
- Department of Nephrology, Klinikum rechts der Isar of the Technical University Munich, Munich, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Rouven Behnisch
- Institute of Medical Biometry, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Morath
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Lutz Renders
- Department of Nephrology, Klinikum rechts der Isar of the Technical University Munich, Munich, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar of the Technical University Munich, Munich, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Paul Schnitzler
- Department of Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Andrea Della Penna
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Klaus Heeg
- Department of Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Stefan Meuer
- Department of Immunology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Martin Zeier
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Thomas Giese
- Department of Immunology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
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4
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Terrec F, Jouve T, Malvezzi P, Janbon B, Naciri Bennani H, Rostaing L, Noble J. Belatacept Use after Kidney Transplantation and Its Effects on Risk of Infection and COVID-19 Vaccine Response. J Clin Med 2021; 10:jcm10215159. [PMID: 34768680 PMCID: PMC8585113 DOI: 10.3390/jcm10215159] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/26/2021] [Accepted: 11/02/2021] [Indexed: 02/07/2023] Open
Abstract
Introduction: Belatacept is a common immunosuppressive therapy used after kidney transplantation (KT) to avoid calcineurin-inhibitor (CNI) use and its related toxicities. It is unclear whether its use exposes KT recipients (KTx) to a greater risk of infection or a poorer response to vaccines. Areas covered: We reviewed PubMed and the Cochrane database. We then summarized the mechanisms and impacts of belatacept use on the risk of infection, particularly opportunistic, in two settings, i.e., de novo KTx and conversion from CNIs. We also focused on COVID-19 infection risk and response to SARS-CoV-2 vaccination in patients whose maintenance immunosuppression relies on belatacept. Expert opinion: When belatacept is used de novo, or after drug conversion the safety profile regarding the risk of infection remains good. However, there is an increased risk of opportunistic infections, mainly CMV disease and Pneumocystis pneumonia, particularly in those with a low eGFR, in older people, in those receiving steroid-based therapy, or those that have an early conversion from CNI to belatacept (i.e., <six months post-transplantation). Thus, we recommend, if possible, delaying conversion from CNI to belatacept until at least six months post-transplantation. Optimal timing seems to be eight months post-transplantation. In addition, KTx receiving belatacept respond poorly to SARS-CoV-2 vaccination.
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Affiliation(s)
- Florian Terrec
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
- School of Medicine, Université Grenoble Alpes, 38043 Grenoble, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Bénédicte Janbon
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Hamza Naciri Bennani
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
- School of Medicine, Université Grenoble Alpes, 38043 Grenoble, France
- Correspondence: ; Tel.: +33-4-76-76-54-60
| | - Johan Noble
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
- School of Medicine, Université Grenoble Alpes, 38043 Grenoble, France
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5
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Andreasen PB, Rezahosseini O, Møller DL, Wareham NE, Thomsen MT, Houmami R, Knudsen AD, Knudsen J, Kurtzhals JAL, Rostved AA, Pedersen CR, Rasmussen A, Nielsen SD. Pneumocystis jirovecii pneumonia in liver transplant recipients in an era of routine prophylaxis. IMMUNITY INFLAMMATION AND DISEASE 2021; 10:93-100. [PMID: 34713963 PMCID: PMC8669693 DOI: 10.1002/iid3.546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/22/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PCP) is an opportunistic infection in organ transplant recipients that may be prevented by antibiotic prophylaxis. We aimed to investigate the incidence rate (IR) of PCP and the related hospitalization and mortality rates in liver transplant recipients in an era of routine prophylaxis. METHODS We included all adult liver transplant recipients transplanted at Rigshospitalet between January 1, 2011 and October 1, 2019. Microbiology data were obtained from the Danish Microbiology Database (MiBa), a national database containing all data from all Departments of Clinical Microbiology in Denmark receiving samples from both hospitals and general practices. According to local guidelines, PCP prophylaxis was initiated 1 week posttransplantation and discontinued after 6 months or sooner in patients experiencing side effects. RESULTS We included 343 liver transplant recipients with 1153 person-years of follow-up (PYFU), of which 269 (78%) received PCP prophylaxis during the first 6 months posttransplantation. Seven (2%) recipients were diagnosed with PCP during follow-up. In the first 6 months posttransplantation and in 269 transplant recipients who received prophylaxis there were zero PCP events while the IR was 32 (95% confidence interval [CI] 2.9-148) per 1000 PYFU in 74 recipient who did not receive prophylaxis. During 7th to 12th month posttransplantation the IR was 20 (95% CI: 5.5-53) per 1000 PYFU. All seven (100%) recipients diagnosed with PCP were hospitalized, however none died. CONCLUSIONS PCP was not detected in liver transplant recipients while on prophylaxis. Though, it worth mentioning that two out of the seven PCP patients received high-dose prednisolone before the PCP event. All liver transplant recipients with PCP were hospitalized, but none died. Randomized clinical trials to determine the optimal duration of prophylaxis are warranted.
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Affiliation(s)
- Philip B Andreasen
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Omid Rezahosseini
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Dina L Møller
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Neval E Wareham
- Centre of Excellence for Personalized Medicine of Infectious Complications in Immune Deficiency, Rigshospitalet, Copenhagen, Denmark
| | - Magda T Thomsen
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ranya Houmami
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Andreas D Knudsen
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jenny Knudsen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jørgen A L Kurtzhals
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Andreas A Rostved
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christian R Pedersen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Susanne D Nielsen
- Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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6
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Wilmes D, Coche E, Rodriguez-Villalobos H, Kanaan N. Fungal pneumonia in kidney transplant recipients. Respir Med 2021; 185:106492. [PMID: 34139578 DOI: 10.1016/j.rmed.2021.106492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
Fungal pneumonia is a dreaded complication encountered after kidney transplantation, complicated by increased mortality and often associated with graft failure. Diagnosis can be challenging because the clinical presentation is non-specific and diagnostic tools have limited sensitivity and specificity in kidney transplant recipients and must be interpreted in the context of the clinical setting. Management is difficult due to the increased risk of dissemination and severity, multiple comorbidities, drug interactions and reduced immunosuppression which should be applied as an important adjunct to therapy. This review will focus on the main causes of fungal pneumonia in kidney transplant recipients including Pneumocystis, Aspergillus, Cryptococcus, mucormycetes and Histoplasma. Epidemiology, clinical presentation, laboratory and radiographic features, specific characteristics will be discussed with an update on diagnostic procedures and treatment.
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Affiliation(s)
- D Wilmes
- Division of Internal Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - E Coche
- Division of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - H Rodriguez-Villalobos
- Division of Microbiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - N Kanaan
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
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7
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Azar MM, Cohen E, Ma L, Cissé OH, Gan G, Deng Y, Belfield K, Asch W, Grant M, Gleeson S, Koff A, Gaston DC, Topal J, Curran S, Kulkarni S, Kovacs JA, Malinis M. Genetic and Epidemiologic Analyses of an Outbreak of Pneumocystis jirovecii Pneumonia among Kidney Transplant Recipients in the United States. Clin Infect Dis 2021; 74:639-647. [PMID: 34017984 DOI: 10.1093/cid/ciab474] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Pneumocystis jiroveciii is an opportunistic fungus that causes Pneumocystis pneumonia (PCP) in immunocompromised hosts. Over an 11-month period, we observed a rise in cases of PCP among kidney-transplant recipients (KTR), prompting an outbreak investigation. METHODS Clinical and epidemiologic data were collected for KTR diagnosed with PCP between July 2019 and May 2020. Pneumocystis strain typing was performed using restriction fragment length polymorphism analyses and multilocus sequence typing in combination with next-generation sequencing. A transmission map was drawn, and a case-control analysis was performed to determine risk factors associated with PCP. RESULTS Nineteen cases of PCP in KTR were diagnosed at a median of 79 months post-transplantation; eight received monthly belatacept infusions. Baseline characteristics were similar for KTR on belatacept versus other regimens; the number of clinic visits was numerically higher for the belatacept group during the study period (median 7.5 vs 3). Molecular typing of respiratory specimens from nine patients revealed coinfection with up to seven P. jirovecii strains per patient. A transmission map suggested multiple clusters of interhuman transmission. In a case-control univariate analysis, belatacept, lower absolute lymphocyte count, non-White race, and more transplant clinic visits were associated with an increased risk of PCP. In multivariate and prediction power estimate analyses, frequent clinic visits was the strongest risk factor for PCP. CONCLUSION Increased clinic exposure appeared to facilitate multiple clusters of nosocomial PCP transmission among KTR. Belatacept was a risk factor for PCP, possibly by increasing clinic exposure through the need for frequent visits for monthly infusions.
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Affiliation(s)
- Marwan M Azar
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven CT, USA
| | - Elizabeth Cohen
- Kidney Transplantation Program, Yale-New Haven Hospital, New Haven, CT, USA
| | - Liang Ma
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, Maryland, USA
| | - Ousmane H Cissé
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, Maryland, USA
| | - Geliang Gan
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven CT, USA
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven CT, USA
| | - Kristen Belfield
- Department of Internal Medicine, Section of Nephrology, Yale School of Medicine, New Haven CT, USA
| | - William Asch
- Kidney Transplantation Program, Yale-New Haven Hospital, New Haven, CT, USA.,Department of Internal Medicine, Section of Nephrology, Yale School of Medicine, New Haven CT, USA
| | - Matthew Grant
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven CT, USA
| | - Shana Gleeson
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven CT, USA
| | - Alan Koff
- Department of Internal Medicine, Section of Infectious Diseases, UC Davis School of Medicine, Sacramento, CA, USA
| | - David C Gaston
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jeffrey Topal
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven CT, USA
| | - Shelly Curran
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, Maryland, USA
| | - Sanjay Kulkarni
- Kidney Transplantation Program, Yale-New Haven Hospital, New Haven, CT, USA.,Department of Surgery, Yale School of Medicine, New Haven CT, USA
| | - Joseph A Kovacs
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, Maryland, USA
| | - Maricar Malinis
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven CT, USA.,Department of Surgery, Yale School of Medicine, New Haven CT, USA
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8
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Perrier Q, Portais A, Terrec F, Cerba Y, Romanet T, Malvezzi P, Bedouch P, Tetaz R, Rostaing L. A Case of Pneumocystis jirovecii Pneumonia under Belatacept and Everolimus: Benefit-Risk Balance between Renal Allograft Function and Infection. Case Rep Nephrol Dial 2021; 11:10-15. [PMID: 33708795 PMCID: PMC7923707 DOI: 10.1159/000510842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/12/2020] [Indexed: 11/20/2022] Open
Abstract
Pneumocystis jirovecii pneumonia is an opportunistic disease usually prevented by trimethoprim-sulfamethoxazole. A 49-year-old HLA-sensitized male with successful late conversion from tacrolimus-based to belatacept-based immunosuppression developed P. jirovecii pneumonia for which he presented several risks factors: low lymphocyte count with no CD4+ T cells detected since 2 years, hypogammaglobulinemia, history of acute cellular rejection 3 years before, and immunosuppressive treatment (belatacept, everolimus). Because of respiratory gravity in the acute phase, the patient was given oxygen, corticosteroids, and trimethoprim-sulfamethoxazole. Thanks to the improvement of respiratory status, and because of the renal impairment, trimethoprim-sulfamethoxazole was converted to atovaquone for 21 days. Indeed, after 1 week on intensive treatment, the benefit-risk balance favored preserving renal function according to respiratory improvement status. P. jirovecii pneumonia prophylaxis for the next 6 months was monthly aerosol of pentamidine. Long-term safety studies or early/late conversion to belatacept did not report on P. jirovecii pneumonia. Four other cases of P. jirovecii pneumonia under belatacept therapy were previously described in patients having no P. jirovecii pneumonia prophylaxis. Studies on the reintroduction of P. jiroveciipneumonia prophylaxis after conversion to belatacept would be of interest. It could be useful to continue regular evaluation within the second-year post-transplantation regarding immunosuppression: T-cell subsets and immunoglobulin G levels.
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Affiliation(s)
- Quentin Perrier
- Department of Clinical Pharmacy, Grenoble Alpes University Hospital, Grenoble, France
| | - Antoine Portais
- Infectious Diseases Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Florian Terrec
- Nephrology, Hemodialysis, Apheresis, and Kidney Transplantation Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Yann Cerba
- Nephrology, Hemodialysis, Apheresis, and Kidney Transplantation Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Thierry Romanet
- Department of Clinical Pharmacy, Grenoble Alpes University Hospital, Grenoble, France
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis, and Kidney Transplantation Department, Grenoble Alpes University Hospital, Grenoble, France
- Université Grenoble-Alpes, Grenoble, France
| | - Pierrick Bedouch
- Department of Clinical Pharmacy, Grenoble Alpes University Hospital, Grenoble, France
- Université Grenoble Alpes, CNRS TIMC-IMAG, UMR 5525, Grenoble, France
| | - Rachel Tetaz
- Department of Clinical Pharmacy, Grenoble Alpes University Hospital, Grenoble, France
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis, and Kidney Transplantation Department, Grenoble Alpes University Hospital, Grenoble, France
- Université Grenoble-Alpes, Grenoble, France
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9
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A Comprehensive Evaluation of Risk Factors for Pneumocystis Jirovecii Pneumonia in Adult Solid Organ Transplant Recipients: a Systematic Review and Meta-Analysis. Transplantation 2020; 105:2291-2306. [PMID: 33323766 DOI: 10.1097/tp.0000000000003576] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND There is no consensus guidance on when to reinitiate Pneumocystis jirovecii pneumonia (PJP) prophylaxis in solid organ transplant (SOT) recipients at increased risk. The 2019 American Society of Transplantation Infectious Diseases Community of Practice (AST IDCOP) guidelines suggested to continue or reinstitute PJP prophylaxis in those receiving intensified immunosuppression for graft rejection, CMV infection, higher dose of corticosteroids, or prolonged neutropenia. METHODS A literature search was conducted evaluating all literature from existence through April 22, 2020 using MEDLINE and EMBASE. (PROSPERO: CRD42019134204) RESULTS:: A total of 30 studies with 413 276 SOT recipients were included. The following factors were associated with PJP development: acute rejection (pooled odds ratio (pOR) = 2.35 (1.69, 3.26), study heterogeneity index (I)= 23.4%), cytomegalovirus (CMV)-related illnesses (pOR = 3.14 (2.30, 4.29), I=48%), absolute lymphocyte count < 500 cells/mm (pOR = 6.29[3.56, 11.13], I 0%), BK-related diseases (pOR = 2.59[1.22, 5.49], I 0%), HLA mismatch ≥ 3 (pOR = 1.83 [1.06, 3.17], I= 0%), rituximab use (pOR =3.03 (1.82, 5.04); I =0%) and polyclonal antibodies use for rejection (pOR = 3.92 [1.87, 8.19], I= 0%). On the other hand, sex, CMV mismatch, interleukin-2 inhibitors, corticosteroids for rejection, and plasmapheresis were not associated with developing PJP. CONCLUSION PJP prophylaxis should be considered in SOT recipients with lymphopenia, BK-related infections and rituximab exposure in addition to the previously mentioned risk factors in the AST IDCOP guidelines.
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10
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Bertrand D, Chavarot N, Gatault P, Garrouste C, Bouvier N, Grall-Jezequel A, Jaureguy M, Caillard S, Lemoine M, Colosio C, Golbin L, Rerolle JP, Thierry A, Sayegh J, Etienne I, Lebourg L, Sberro R, Guerrot D. Opportunistic infections after conversion to belatacept in kidney transplantation. Nephrol Dial Transplant 2020; 35:336-345. [PMID: 32030416 DOI: 10.1093/ndt/gfz255] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 10/29/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Belatacept (bela) rescue therapy seems to be a valuable option for calcineurin inhibitor chronic toxicity in kidney transplantation. Nevertheless, the risk of infection associated with bela is not well reported. METHODS We report the rate of opportunistic infections (OPI) after a switch to bela in a multicentric cohort of 280 kidney transplant patients. RESULTS Forty-two OPI occurred in 34 patients (12.1%), on average 10.8 ± 11.3 months after the switch. With a cumulative exposure of 5128 months of bela treatment, we found an incidence of 0.008 OPI/month of exposure, and 9.8 OPI/100 person-years. The most common OPI was cytomegalovirus (CMV) disease in 18/42 OPI (42.9%) and pneumocystis pneumonia in 12/42 OPI (28.6%). Two patients presented a progressive multifocal leucoencephalopathy and two patients developed a cerebral Epstein-Barr virus-induced post-transplant lymphoproliferative disease. OPI led to death in 9/34 patients (26.5%) and graft failure in 4/34 patients (11.8%). In multivariate analysis, estimated glomerular filtration rate <25/mL/min/1.73 m2 on the day of the switch and the use of immunosuppressive agents before transplantation were associated with the occurrence of OPI. We found a higher rate of infection-related hospitalization (24.1 versus 12.3/100 person-years, P = 0.0007) and also a higher rate of OPI (13.2 versus 6.7/100 person-years, P = 0.005) in the early conversion group (within 6 months). CONCLUSIONS The risk of OPI is significant post-conversion to bela and may require additional monitoring and prophylactic therapy, particularly regarding pneumocystis pneumonia and CMV disease. These data need to be confirmed in a larger case-control study.
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Affiliation(s)
| | - Nathalie Chavarot
- Department of Adult Kidney Transplantation, Necker-Enfants Malades University Hospital, Paris, France
| | - Philippe Gatault
- Department of Nephrology, Tours University Hospital, Tours, France
| | - Cyril Garrouste
- Department of Nephrology, Clermont Ferrand University Hospital, Clermont Ferrand, France
| | - Nicolas Bouvier
- Department of Nephrology, Caen University Hospital, Caen, France
| | | | - Maïté Jaureguy
- Department of Nephrology, Amiens University Hospital, Amiens, France
| | - Sophie Caillard
- Department of Nephrology, Strasbourg University Hospital, Strasbourg, France
| | - Mathilde Lemoine
- Department of Nephrology, European Georges Pompidou University Hospital, Paris, France
| | | | - Léonard Golbin
- Department of Nephrology, Rennes University Hospital, Rennes, France
| | | | - Antoine Thierry
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Johnny Sayegh
- Department of Nephrology, Angers University Hospital, Angers, France
| | - Isabelle Etienne
- Department of Nephrology, Rouen University Hospital, Rouen, France
| | - Ludivine Lebourg
- Department of Nephrology, Rouen University Hospital, Rouen, France
| | - Rebecca Sberro
- Department of Adult Kidney Transplantation, Necker-Enfants Malades University Hospital, Paris, France
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11
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Chen J, He T, Li X, Wang X, Peng L, Ma L. Metagenomic Next-Generation Sequencing in Diagnosis of a Case of Pneumocystis jirovecii Pneumonia in a Kidney Transplant Recipient and Literature Review. Infect Drug Resist 2020; 13:2829-2836. [PMID: 32884306 PMCID: PMC7431457 DOI: 10.2147/idr.s257587] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022] Open
Abstract
Background Despite the increasing incidences of Pneumocystis jirovecii pneumonia (PCP) in renal transplant recipients, diagnosis of PCP remains challenging due to its nonspecific clinical presentation and the inadequate performance of conventional diagnostic methods. There is a need for novel diagnostic methods. Case Presentation A 27-year-old woman developed acute pneumonia 4 months after renal transplantation. Blood tests revealed a low CD4 count, a normal 1,3-beta-D-glucan level and other changes typical of inflammatory responses. Chest imaging showed bilateral diffuse infiltrates. Microscopic examination of stained sputum and bronchoalveolar lavage fluid (BALF) smear specimens did not find Pneumocystis organisms. There was also no evidence for other pathogens known to cause pneumonia in various antibody and culture tests. Direct metagenomic next-generation sequencing (mNGS) analysis of a BALF specimen identified a large number of P. jirovecii reads, allowing to confirm the diagnosis of PCP. Following treatment with trimethoprim-sulfamethoxazole for two weeks, the patient was cured and discharged. Conclusion This case report supports the value of mNGS in diagnosing PCP, highlights the inadequate sensitivity of conventional diagnostic methods for PCP, and calls for the need to add PCP prophylaxis to the current Diagnosis and Treatment Guideline of Invasive Fungal Infections in Solid Organ Transplant Recipients in China.
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Affiliation(s)
- Jie Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Ting He
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Xiujun Li
- Department of Pathology, College of Basic Medicine, Chongqing Medical University, Chongqing, People's Republic of China
| | - Xue Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Li Peng
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Liang Ma
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
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12
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Freiwald T, Büttner S, Cheru NT, Avaniadi D, Martin SS, Stephan C, Pliquett RU, Asbe-Vollkopf A, Schüttfort G, Jacobi V, Herrmann E, Geiger H, Hauser IA. CD4 + T cell lymphopenia predicts mortality from Pneumocystis pneumonia in kidney transplant patients. Clin Transplant 2020; 34:e13877. [PMID: 32277846 DOI: 10.1111/ctr.13877] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 03/24/2020] [Accepted: 04/01/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PcP) remains a life-threatening opportunistic infection after solid organ transplantation, even in the era of Pneumocystis prophylaxis. The association between risk of developing PcP and low CD4+ T cell counts has been well established. However, it is unknown whether lymphopenia in the context of post-renal transplant PcP increases the risk of mortality. METHODS We carried out a retrospective analysis of a cohort of kidney transplant patients with PcP (n = 49) to determine the risk factors for mortality associated with PcP. We correlated clinical and demographic data with the outcome of the disease. For CD4+ T cell counts, we used the Wilcoxon rank sum test for in-hospital mortality and a Cox proportional-hazards regression model for 60-day mortality. RESULTS In univariate analyses, high CRP, high neutrophils, CD4+ T cell lymphopenia, mechanical ventilation, and high acute kidney injury network stage were associated with in-hospital mortality following presentation with PcP. In a receiver-operator characteristic (ROC) analysis, an optimum cutoff of ≤200 CD4+ T cells/µL predicted in-hospital mortality, CD4+ T cell lymphopenia remained a risk factor in a Cox regression model. CONCLUSIONS Low CD4+ T cell count in kidney transplant recipients is a biomarker for disease severity and a risk factor for in-hospital mortality following presentation with PcP.
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Affiliation(s)
- Tilo Freiwald
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany.,Immunoregulation Section, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA.,Complement and Inflammation Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Stefan Büttner
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Nardos T Cheru
- Immunoregulation Section, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Despina Avaniadi
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Simon S Martin
- Department of Radiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Christoph Stephan
- Department of Infectious Diseases, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Rainer U Pliquett
- Department of Nephrology and Diabetology, Carl-Thiem Hospital Cottbus, Cottbus, Germany
| | - Aida Asbe-Vollkopf
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Gundolf Schüttfort
- Department of Infectious Diseases, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Volkmar Jacobi
- Department of Radiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Eva Herrmann
- Institute for Biostatistics and Mathematical Modeling, Goethe-University, Frankfurt, Germany
| | - Helmut Geiger
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Ingeborg A Hauser
- Medical Clinic III, Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
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13
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Lee S, Park Y, Kim SG, Ko EJ, Chung BH, Yang CW. The impact of cytomegalovirus infection on clinical severity and outcomes in kidney transplant recipients with Pneumocystis jirovecii pneumonia. Microbiol Immunol 2020; 64:356-365. [PMID: 31994768 DOI: 10.1111/1348-0421.12778] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/21/2020] [Accepted: 01/25/2020] [Indexed: 02/06/2023]
Abstract
Cytomegalovirus (CMV) infection is associated with Pneumocystis jirovecii pneumonia (PJP) in kidney transplant recipients (KTRs), but its impact on clinical severity and outcomes in KTRs with PJP is unknown. We reviewed 1994 medical records of KTRs from January 1997 to March 2019. PJP or CMV infection was diagnosed by polymerase chain reaction or culturing using blood or respiratory specimens. We divided patients into PJP and PJP+CMV groups, and evaluated the clinical severity and outcomes. Fifty two patients had PJP (2.6%) in the whole study cohort. Among patients with PJP, 38 (73.1%) had PJP alone and 14 (26.9%) had combined PJP and CMV co-infection. The PJP+CMV group showed worse laboratory findings (serum albumin and C-reactive protein, P = 0.010 for both) and higher requirement of continuous renal replacement therapy than the PJP group (P = 0.050). The pneumonia severity was worse in the PJP+CMV group than in the PJP group (P < 0.05), and CMV infection was a high risk factor of pneumonia severity (odds ratio 16.0; P = 0.002). The graft function was worse in the PJP+CMV group (P < 0.001), and the incidence of graft failure was higher in the PJP+CMV group than in the PJP group (85.7% vs 36.8%; P < 0.001). Mortality was double in the PJP+CMV group than in the PJP group, but not statistically significant (21.4% vs 10.5%; P = 0.370). Our results show that approximately one in four patients with PJP after kidney transplantation develops CMV with increased clinical severity and risk of graft failure. The possibility of increased clinical severity and worse clinical outcomes by CMV co-infection should be considered in KTRs with PJP.
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Affiliation(s)
- Sua Lee
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Yohan Park
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Seong Gyu Kim
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Eun Jeong Ko
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Convergent Research Consortium for Immunologic Disease, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Byung Ha Chung
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Convergent Research Consortium for Immunologic Disease, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Chul Woo Yang
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Convergent Research Consortium for Immunologic Disease, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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14
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Jin F, Liu XH, Chen WC, Fan ZL, Wang HL. High initial (1, 3) Beta-d-Glucan concentration may be a predictor of satisfactory response of c aspofungin combined with TMP/SMZ for HIV-negative patients with moderate to severe Pneumocystis jirovecii pneumonia. Int J Infect Dis 2019; 88:141-148. [PMID: 31442630 DOI: 10.1016/j.ijid.2019.08.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/10/2019] [Accepted: 08/15/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES The aim of this study was to investigate the efficacy of combination therapy of caspofungin and TMP/SMZ (trimethoprim/sulfamethoxazole) in moderate to severe pneumocystis jirovecii pneumonia (PJP) in patients without human immunodeficiency virus infection (HIV) and the relationship between therapeutic effect and plasma (1, 3) Beta-d-Glucan (BDG) levels. METHODS We retrospectively reviewed HIV-negative patients with PJP diagnosed in our department, who were treated with combination therapy of caspofungin and TMP/SMZ or monotherapy of TMP/SMZ during a six and a half year period. RESULTS A total of 126 moderate to severe PJP patients were enrolled in the study. In the multivariate analysis, low lymphocyte counts, high serum lactate dehydrogenase levels at the diagnosis of PJP and progression to shock were significant risk factors for death. In all patients, there was no significant difference in risk of death at 3 months. In the group of BDG≥800pg/m, patients receiving combination therapy was associated with a significantly decreased risk of death at 3 months, whereas in the group of BDG<800pg/ml, there were no statistically significant difference in survival rate between the two treatment regimens. CONCLUSION High initial plasma (1, 3) Beta-d-Glucan concentration may be a predictor of satisfactory caspofungin response to HIV-negative patients with PJP. Based on our findings, we suggest the choice of combination therapy with caspofungin and TMP/SMZ as the initial treatment when BDG≥800pg/ml in moderate to severe HIV-negative patients with PJP.
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Affiliation(s)
- Fan Jin
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Xiao-Hang Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Wen-Can Chen
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Zhang-Ling Fan
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Huan-Ling Wang
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China; Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China.
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15
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Van Laecke S, Kerre T, Nagler EV, Maes B, Caluwe R, Schepers E, Glorieux G, Van Biesen W, Verbeke F. Hereditary polycystic kidney disease is characterized by lymphopenia across all stages of kidney dysfunction: an observational study. Nephrol Dial Transplant 2019; 33:489-496. [PMID: 28387829 DOI: 10.1093/ndt/gfx040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 02/08/2017] [Indexed: 01/08/2023] Open
Abstract
Background Polycystic kidney disease (PKD) is characterized by urinary tract infections and extrarenal abnormalities such as an increased risk of cancer. As mutations in polycystin-1 and -2 are associated with decreased proliferation of immortalized lymphoblastoid cells in PKD, we investigated whether lymphopenia could be an unrecognized trait of PKD. Methods We studied 700 kidney transplant recipients with (n = 126) or without PKD at the time of kidney transplantation between 1 January 2003 and 31 December 2014 at Ghent University Hospital. We also studied 204 patients with chronic kidney disease (CKD) with PKD and 204 matched CKD patients without PKD across comparable CKD strata with assessment between 1 January 1999 and 1 February 2016 at three renal outpatient clinics. We compared lymphocyte counts with multiple linear regression analysis to adjust for potential confounders. We analysed flow cytometric immunophenotyping data and other haematological parameters. Results Lymphocyte counts were 264/µL [95% confidence interval (CI) 144-384] and 345/µL (95% CI 245-445) (both P < 0.001) lower in the end-stage kidney disease (ESKD) and CKD cohort, respectively, after adjustment for age, sex, ln(C-reactive protein) and estimated glomerular filtration rate (in the CKD cohort only). In particular, CD8+ T and B lymphocytes were significantly lower in transplant recipients with versus without PKD (P < 0.001 for both). Thrombocyte and monocyte counts were lower in patients with versus without PKD in both cohorts (P < 0.001 for all analyses except P = 0.01 for monocytes in the ESKD cohort). Conclusion PKD is characterized by distinct cytopenias and especially lymphopenia, independent of kidney function. This finding has the potential to alter our therapeutic approach to patients with PKD.
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Affiliation(s)
| | - Tessa Kerre
- Department of Haematology and Clinical Chemistry, Microbiology and Immunology, Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Evi V Nagler
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - Bart Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | | | - Eva Schepers
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - Griet Glorieux
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - Wim Van Biesen
- Renal Division, Ghent University Hospital, Ghent, Belgium
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16
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Kabir V, Maertens J, Kuypers D. Fungal infections in solid organ transplantation: An update on diagnosis and treatment. Transplant Rev (Orlando) 2018; 33:77-86. [PMID: 30579665 DOI: 10.1016/j.trre.2018.12.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/10/2018] [Accepted: 12/11/2018] [Indexed: 12/14/2022]
Abstract
Invasive fungal infections constitute an important cause of morbidity and mortality in solid organ transplantation recipients. Since solid organ transplantation is an effective therapy for many patients with end-stage organ failure, prevention and treatment of fungal infections are of vital importance. Diagnosis and management of these infections, however, remain difficult due to the variety of clinical symptoms in addition to the lack of accurate diagnostic methods. The use of fungal biomarkers can lead to an increased diagnostic accuracy, resulting in improved clinical outcomes. The evidence for optimal prophylactic approaches remains inconclusive, which results in considerable variation in the administration of prophylaxis. The implementation of a standard protocol for prophylaxis remains difficult as previous treatment regimens, which can alter the distribution of different pathogens, affect the outcome of antifungal susceptibility testing. Furthermore, the increasing use of antifungals also contributes to incremental costs and the risk of development of drug resistance. This review will highlight risk factors, clinical manifestations and timing of fungal infections and will focus predominately on the current evidence for diagnosis and management of fungal infections.
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Affiliation(s)
- Vincent Kabir
- KU Leuven, Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Johan Maertens
- KU Leuven, Laboratory of Clinical Bacteriology and Mycology, Herestraat 49, 3000 Leuven, Belgium.
| | - Dirk Kuypers
- KU Leuven, Laboratory of Nephrology, Herestraat 49, 3000 Leuven, Belgium; Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium.
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17
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Ricci G, Santos DW, Kovacs JA, Nishikaku AS, de Sandes-Freitas TV, Rodrigues AM, Kutty G, Affonso R, Silva HT, Medina-Pestana JO, de Franco MF, Colombo AL. Genetic diversity of Pneumocystis jirovecii from a cluster of cases of pneumonia in renal transplant patients: Cross-sectional study. Mycoses 2018; 61:845-852. [PMID: 29992629 DOI: 10.1111/myc.12823] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 06/11/2018] [Accepted: 07/01/2018] [Indexed: 12/25/2022]
Abstract
Pneumocystis jirovecii can cause severe potentially life-threatening pneumonia (PCP) in kidney transplant patients. Prophylaxis of patients against PCP in this setting is usually performed during 6 months after transplantation. The aim of this study is to describe the molecular epidemiology of a cluster of PCP in renal transplant recipients in Brazil. Renal transplant patients who developed PCP between May and December 2011 had their formalin-fixed paraffin-embedded (FFPE) lung biopsy samples analysed. Pneumocystis jirovecii 23S mitochondrial large subunit of ribosomal RNA (23S mtLSU-rRNA), 26S rRNA, and dihydropteroate synthase (DHPS) genes were amplified by polymerase chain reaction (PCR), sequenced, and analysed for genetic variation. During the study period, 17 patients developed PCP (only four infections were documented within the first year after transplantation) and six (35.3%) died. Thirty FFPE samples from 11 patients, including one external control HIV-infected patient, had fungal DNA successfully extracted for further amplification and sequencing for all three genes. A total of five genotypes were identified among the 10 infected patients. Of note, four patients were infected by more than one genotype and seven patients were infected by the same genotype. DNA extracted from FFPE samples can be used for genotyping; this approach allowed us to demonstrate that multiple P. jirovecii strains were responsible for this cluster, and one genotype was found infecting seven patients. The knowledge of the causative agents of PCP may help to develop new initiatives for control and prevention of PCP among patients undergoing renal transplant and improve routine PCP prophylaxis.
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Affiliation(s)
- Giannina Ricci
- Special Mycology Laboratory, Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Daniel Wagner Santos
- Special Mycology Laboratory, Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.,Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, SP, Brazil
| | - Joseph A Kovacs
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Angela Satie Nishikaku
- Special Mycology Laboratory, Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | - Anderson Messias Rodrigues
- Molecular Biology Division, Department of Microbiology, Immunology and Parasitology (DMIP), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Geetha Kutty
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Regina Affonso
- Biotechnology Center, Nuclear and Energy Research Institute (IPEN), São Paulo, SP, Brazil
| | | | | | | | - Arnaldo Lopes Colombo
- Special Mycology Laboratory, Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
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Mascia G, Argiolas D, Carta E, Michittu MB, Piredda GB. Acute Kidney Injury Secondary to Hypercalcemia in a Kidney Transplant Patient With Pneumocystis jirovecii Pneumonia: A Case Report. Transplant Proc 2018; 51:220-222. [PMID: 30736974 DOI: 10.1016/j.transproceed.2018.04.077] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Persistent hyperparathyroidism is one of the main causes of hypercalcemia following kidney transplantation; differential diagnosis is required. CASE PRESENTATION We report the case of a 61-year-old kidney transplant recipient who underwent transplant in September 2016. She was admitted in March 2017 presenting with a 3-week history of asthenia, hypotension, and cough. Laboratory analysis showed acute kidney injury with hypercalcemia and elevation of inflammatory markers. She was initially treated with hydration therapy. A few days after admission she developed respiratory failure: chest computed tomography showed a ground-glass pattern. A diagnosis of Pneumocystis jirovecii was made on bronchoalveolar lavage. A subsequent graft biopsy was performed that revealed intratubular calcium deposition without signs of rejection. The patient was given trimethoprim/sulfamethoxazole, with improvement in pulmonary and renal function as well as improvement in hypercalcemia. CONCLUSIONS P jirovecii infection can trigger activation of intra-alveolar macrophages that leads to extrarenal vitamin D production with subsequent hypercalcemia. This rare event should be considered in renal transplant patients with pulmonary infection accompanied by hypercalcemia. In our case, hypercalcemia also provoked acute kidney injury.
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Affiliation(s)
- G Mascia
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
| | - D Argiolas
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
| | - E Carta
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy.
| | - M B Michittu
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
| | - G B Piredda
- Renal Transplant Unit, AO Brotzu, Cagliari, Italy
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Brakemeier S, Pfau A, Zukunft B, Budde K, Nickel P. Prophylaxis and treatment of Pneumocystis Jirovecii pneumonia after solid organ transplantation. Pharmacol Res 2018; 134:61-67. [PMID: 29890253 DOI: 10.1016/j.phrs.2018.06.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 03/21/2018] [Accepted: 06/07/2018] [Indexed: 12/17/2022]
Abstract
Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection diagnosed in immunocompromized patients. After solid organ transplantation, early infection has decreased as a result of effective prophylaxis, but late infections and even outbreaks caused by interpatient transmission of pneumocystis by air are present in the SOT community. Different risk factors for PJP have been described and several indications for PJP prophylaxis have to be considered by clinicians in patients even years after transplantation. Diagnosis of PJP is confirmed by microscopy and immunofluorescence staining of bronchial fluid but PCR as well as serum ß-D-Glucan analysis have become increasingly valuable diagnostic tools. Treatment of choice is Trimethoprim/sulfamethoxazole and early treatment improves prognosis. However, mortality of PJP in solid organ transplant patients is still high and many aspects including the optimal management of immunosuppression during PJP treatment require further investigations.
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Affiliation(s)
- Susanne Brakemeier
- Department of Nephrology and Medical Intensive Care, Charité, Berlin, Germany.
| | - Anja Pfau
- Department of Nephrology and Medical Intensive Care, Charité, Berlin, Germany
| | - Bianca Zukunft
- Department of Nephrology and Medical Intensive Care, Charité, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité, Berlin, Germany
| | - Peter Nickel
- Department of Nephrology and Medical Intensive Care, Charité, Berlin, Germany
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Deziel PJ, Razonable R. Anti-infective chemoprophylaxis after solid-organ transplantation. Expert Rev Clin Immunol 2018; 14:469-479. [PMID: 29764228 DOI: 10.1080/1744666x.2018.1476852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Solid organ transplant (SOT) recipients are at high risk of opportunistic infections due to bacterial, viral, fungal, and parasitic pathogens. Anti-infective prophylaxis is a time-tested proven strategy for the prevention of these infections after SOT. Areas covered: The current recommendations for the prevention of surgical site infections, herpes simplex, cytomegalovirus, invasive fungal infections, and selected parasitic diseases are highlighted. Recent peer-reviewed publications on the prevention of infection after SOT were reviewed and their significance was discussed in the context of the current recommendations for preventing infectious complications. Expert commentary: The authors comment on the current approaches to infection prevention in transplant recipients, and discuss how these recommendations are implemented in their clinical practice. Notable findings published during the past year were highlighted, and their clinical significance was interpreted in the context of current recommendations. The evolution of diagnostic and immunologic assays was emphasized, with focus on their potential role in optimizing the current antimicrobial approaches to infection prevention after SOT.
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Affiliation(s)
- Paul J Deziel
- a Division of Infectious Diseases, The William J von Liebig Center for Transplantation and Clinical Regeneration , Mayo Clinic College of Medicine and Science, Mayo Clinic , Rochester , MN , USA
| | - Raymund Razonable
- a Division of Infectious Diseases, The William J von Liebig Center for Transplantation and Clinical Regeneration , Mayo Clinic College of Medicine and Science, Mayo Clinic , Rochester , MN , USA
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Ling J, Anderson T, Warren S, Kirkland G, Jose M, Yu R, Yew S, Mcfadyen S, Graver A, Johnson W, Jeffs L. Hypercalcaemia preceding diagnosis of Pneumocystis jirovecii pneumonia in renal transplant recipients. Clin Kidney J 2017; 10:845-851. [PMID: 29225815 PMCID: PMC5716089 DOI: 10.1093/ckj/sfx044] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 04/19/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The overall incidence of Pneumocystis jirovecii pneumonia (PJP) in solid organ transplant recipients is 5-15%. A timely diagnosis of PJP is difficult and relies on imaging and detection of the organism. METHODS We present a case series of four patients displaying hypercalcaemia with an eventual diagnosis of PJP and document the management of the outbreak with a multidisciplinary team approach. We discuss the underlying pathophysiology and previous reports of hypercalcaemia preceding a diagnosis of PJP. We also reviewed the evidence concerning PJP diagnosis and treatment. RESULTS Within our renal transplant cohort, four patients presented within 7 months with hypercalcaemia followed by an eventual diagnosis of PJP. We measured their corrected calcium, parathyroid hormone (PTH), 1,25-dihydroxycholecalciferol [1,25-(OH)2D3] and 25-hydroxycholecalciferol [25(OH)D] levels at admission and following treatment of PJP. All four patients diagnosed with PJP were 4-20 years post-transplantation. Three of the four patients demonstrated PTH-independent hypercalcaemia (corrected calcium >3.0 mmol/L). The presence of high 1,25(OH)2D3 and low 25(OH)D levels suggest negation of the negative feedback mechanism possibly due to an extrarenal source; in this case, the alveolar macrophages. All four patients had resolution of their hypercalcaemia after treatment of PJP. CONCLUSIONS Given the outbreak of PJP in our renal transplant cohort, and based on previous experience from other units nationally, we implemented cohort-wide prophylaxis with trimethoprim-sulphamethoxazole for 12 months in consultation with our local infectious diseases unit. Within this period there have been no further local cases of PJP.
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Affiliation(s)
- Jonathan Ling
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Tara Anderson
- Department of Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Sanchia Warren
- Department of Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Geoffrey Kirkland
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Matthew Jose
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Richard Yu
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Steven Yew
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Samantha Mcfadyen
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Alison Graver
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - William Johnson
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Lisa Jeffs
- Department of Nephrology, Royal Hobart Hospital, Hobart, Tasmania, Australia
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Pneumocystis carinii Infection in a Renal Transplant Recipient Presented as Walking Pneumonia Occurring 18 Years After Transplantation: A Case Report. IRANIAN RED CRESCENT MEDICAL JOURNAL 2017. [DOI: 10.5812/ircmj.13742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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