1
|
Coussement J, Bansal SB, Scemla A, Svensson MHS, Barcan LA, Smibert OC, Clemente WT, Lopez-Medrano F, Hoffman T, Maggiore U, Catalano C, Hilbrands L, Manuel O, DU Toit T, Shern TKY, Chowdhury N, Viklicky O, Oberbauer R, Markowicz S, Kaminski H, Lafaurie M, Pierrotti LC, Cerqueira TL, Yahav D, Kamar N, Kotton CN. Initial empirical antibiotic therapy in kidney transplant recipients with pyelonephritis: A global survey of current practice and opinions across 19 countries on six continents. Transpl Infect Dis 2024:e14362. [PMID: 39185755 DOI: 10.1111/tid.14362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 08/03/2024] [Accepted: 08/09/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Despite the burden of pyelonephritis after kidney transplantation, there is no consensus on initial empirical antibiotic management. METHODS We surveyed clinicians throughout the world on their practice and opinions about the initial empirical therapy of post-transplant pyelonephritis, using clinical vignettes. A panel of experts from 19 countries on six continents designed this survey, and invited 2145 clinicians to participate. RESULTS A total of 721 clinicians completed the survey (response rate: 34%). In the hypothetical case of a kidney transplant recipient admitted with pyelonephritis but not requiring intensive care, most respondents reported initiating either a 3rd-generation cephalosporin (37%) or piperacillin-tazobactam (21%) monotherapy. Several patient-level factors dictated the selection of broader-spectrum antibiotics, including having a recent urine culture showing growth of a resistant organism (85% for extended-spectrum ß-lactamase-producing organisms, 90% for carbapenemase-producing organisms, and 94% for Pseudomonas aeruginosa). Respondents attributed high importance to the appropriateness of empirical therapy, which 87% judged important to prevent mortality. Significant practice and opinion variations were observed between and within countries. CONCLUSION High-quality studies are needed to guide the empirical management of post-transplant pyelonephritis. In particular, whether prior urine culture results should systematically be reviewed and considered remains to be determined. Studies are also needed to clarify the relationship between the appropriateness of initial empirical therapy and outcomes of post-transplant pyelonephritis.
Collapse
Affiliation(s)
- Julien Coussement
- Department of Infectious Diseases, Guadeloupe University Hospital, Les Abymes, France
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Shyam B Bansal
- Department of Nephrology, Medanta-Medicity, Gurgaon, India
| | - Anne Scemla
- Department of Kidney Transplantation, Hôpital Necker-Enfants Malades, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - My H S Svensson
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Laura A Barcan
- Internal Medicine Department, Infectious Diseases Section, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Olivia C Smibert
- Department of Infectious Diseases, Austin Health, Heidelberg, Australia
| | - Wanessa T Clemente
- Department of Laboratory Medicine, Transplant Program, Hospital das Clínicas-Universidade Federal de Minas Gerais (UFMG), School of Medicine (UFMG), Belo Horizonte, Brazil
| | - Francisco Lopez-Medrano
- Department of Medicine, Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Tomer Hoffman
- Infectious Diseases Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Umberto Maggiore
- Department of Medicine and Surgery, Kidney-Pancreas Transplant Unit, University of Parma, Parma, Italy
| | - Concetta Catalano
- Department of Nephrology, Dialysis and Kidney Transplantation, CUB-Hôpital Erasme, Brussels, Belgium
| | - Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Oriol Manuel
- Transplantation Centre and Service of Infectious Diseases, University Hospital of Lausanne, Lausanne, Switzerland
| | - Tinus DU Toit
- Transplant Unit, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | | | | | - Ondrej Viklicky
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Rainer Oberbauer
- Division of Nephrology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Samuel Markowicz
- Department of Infectious Diseases, Guadeloupe University Hospital, Les Abymes, France
| | - Hannah Kaminski
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
| | - Matthieu Lafaurie
- Infectious Diseases Unit, St-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Ligia C Pierrotti
- Infectious Diseases Division, Hospital das Clínicas, University of São Paulo Medical School, Sao Paulo, Brazil
| | - Tiago L Cerqueira
- Department of Kidney Transplant, Hospital Evangelico de Minas Gerais, Belo Horizonte, Brazil
| | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Toulouse Rangueil University Hospital, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University Paul Sabatier, Toulouse, France
| | - Camille N Kotton
- Transplant Infectious Disease and Compromised Host Program, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Tarragoni R, Congiu G, Mella A, Augelli G, Fop F, Dolla C, Gallo E, Di Vico MC, Faletti R, Bosio A, Gontero P, Costa C, Cavallo R, Mariano F, Corcione S, De Rosa FG, Fonio P, Biancone L. Different profiles of acute graft pyelonephritis among kidney recipients from standard or elderly donors. Front Med (Lausanne) 2024; 11:1342992. [PMID: 38808134 PMCID: PMC11130444 DOI: 10.3389/fmed.2024.1342992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/30/2024] [Indexed: 05/30/2024] Open
Abstract
Background Acute graft pyelonephritis (AGPN) is a relatively common complication in kidney transplants (KTs); however, the effects on allograft function, diagnostic criteria, and risk factors are not well established. Methods Retrospective analysis of all consecutive adult KTs was performed between 01 January 2011 and 31 December 2018 (follow-up ended on 31 December 2019) to examine the association between the diagnosis of AGPN (confirmed with magnetic resonance imaging [MRI]) during the first post-transplantation year and graft outcomes. Results Among the 939 consecutive KTs (≈50% with donors ≥60 years), we identified 130 MRI-confirmed AGPN episodes, with a documented association with recurrent and multidrug-resistant bacterial urinary tract infections (UTIs) (p < 0.005). Ureteral stenosis was the only risk factor associated with AGPN (OR 2.9 [95% CI, 1.6 to 5.2]). KTs with AGPN had a decreased allograft function at the first year (ΔeGFR 6 mL/min/1.73 m2 [-2-15] in non-AGPN vs. -0.2 [-6.5-8.5] in AGPN, p < 0.001), with similar and negative profiles in KTs from standard or elderly donors. However, only KTs with AGPN and a donor <60 years showed reduced death-censored graft survival (p = 0.015); most of this subgroup received anti-thymocyte globulin (ATG) induction (40.4% vs. 17.7%), and their MRI presented either a multifocal AGPN pattern (73.9% vs. 56.7%) or abscedation (28.3% vs. 11.7%). No difference was noted in death-censored graft survival between early (<3 months post-KT) or late (3-12 months) AGPN, solitary/recurrent forms, or types of multidrug-resistant pathogens. Linear regression confirmed the independent role of multifocal pattern, abscedation, ATG induction, and donor age on the eGFR at the first year. Conclusion AGPN, influenced by multifocal presentation, ATG induction, donor age, and abscedation, affects kidney function and significantly impacts allograft survival in KTs with donors <60 years.
Collapse
Affiliation(s)
- Rita Tarragoni
- Renal Transplantation Center “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | - Giovanni Congiu
- Renal Transplantation Center “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | - Alberto Mella
- Renal Transplantation Center “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | - Giovanni Augelli
- Renal Transplantation Center “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | - Fabrizio Fop
- Renal Transplantation Center “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | - Caterina Dolla
- Renal Transplantation Center “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | - Ester Gallo
- Renal Transplantation Center “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | - Maria Cristina Di Vico
- Renal Transplantation Center “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | - Riccardo Faletti
- Radiology Unit, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Andrea Bosio
- Division of Urology, Department of Surgical Sciences, Torino School of Medicine, AOU Città Della Salute e Della Scienza, Turin, Italy
| | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, Torino School of Medicine, AOU Città Della Salute e Della Scienza, Turin, Italy
| | - Cristina Costa
- Microbiology and Virology Unit, University of Turin, Turin, Italy
| | - Rossana Cavallo
- Microbiology and Virology Unit, University of Turin, Turin, Italy
| | - Filippo Mariano
- Division of Urology, Department of Surgical Sciences, Torino School of Medicine, AOU Città Della Salute e Della Scienza, Turin, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, AOU Città Della Salute e Della Scienza, University of Turin, Turin, Italy
| | - Francesco Giuseppe De Rosa
- Department of Medical Sciences, Infectious Diseases, AOU Città Della Salute e Della Scienza, University of Turin, Turin, Italy
| | - Paolo Fonio
- Radiology Unit, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Luigi Biancone
- Renal Transplantation Center “A. Vercellone,” Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| |
Collapse
|
3
|
Barrett-Chan E, Wang L, Bone J, Thachil A, Vytlingam K, Blydt-Hansen T. Optimizing the approach to monitoring allograft inflammation using serial urinary CXCL10/creatinine testing in pediatric kidney transplant recipients. Pediatr Transplant 2024; 28:e14718. [PMID: 38553815 DOI: 10.1111/petr.14718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/04/2024] [Accepted: 02/05/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Urinary CXCL10/creatinine (uCXCL10/Cr) is proposed as an effective biomarker of subclinical rejection in pediatric kidney transplant recipients. This study objective was to model implementation in the clinical setting. METHODS Banked urine samples at a single center were tested for uCXCL10/Cr to validate published thresholds for rejection diagnosis (>80% specificity). The positive predictive value (PPV) for rejection diagnosis for uCXCL10/Cr-indicated biopsy was modeled with first-positive versus two-test-positive approaches, with accounting for changes associated with urinary tract infection (UTI), BK and CMV viremia, and subsequent recovery. RESULTS Seventy patients aged 10.5 ± 5.6 years at transplant (60% male) had n = 726 urine samples with n = 236 associated biopsies (no rejection = 167, borderline = 51, and Banff 1A = 18). A threshold of 12 ng/mmol was validated for Banff 1A versus no-rejection diagnosis (AUC = 0.74, 95% CI = 0.57-0.92). The first-positive test approach (n = 69) did not resolve a clinical diagnosis in 38 cases (55%), whereas the two-test approach resolved a clinical diagnosis in the majority as BK (n = 17/60, 28%), CMV (n = 4/60, 7%), UTI (n = 8/60, 13%), clinical rejection (n = 5/60, 8%), and transient elevation (n = 18, 30%). In those without a resolved clinical diagnosis, PPV from biopsy for subclinical rejection is 24% and 71% (p = .017), for first-test versus two-test models, respectively. After rejection treatment, uCXCL10/Cr level changes were all concordant with change in it-score. Sustained uCXCL10/Cr after CMV and BK viremia resolution was associated with later acute rejection. CONCLUSIONS Urinary CXCL10/Cr reliably identifies kidney allograft inflammation. These data support a two-test approach to reliably exclude other clinically identifiable sources of inflammation, for kidney biopsy indication to rule out subclinical rejection.
Collapse
Affiliation(s)
| | - Li Wang
- University of British Columbia, Vancouver, British Columbia, Canada
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Jeffrey Bone
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Amy Thachil
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevin Vytlingam
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Tom Blydt-Hansen
- University of British Columbia, Vancouver, British Columbia, Canada
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| |
Collapse
|
4
|
Courjon J, Neofytos D, van Delden C. Bacterial infections in solid organ transplant recipients. Curr Opin Organ Transplant 2024; 29:155-160. [PMID: 38205868 DOI: 10.1097/mot.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
PURPOSE OF REVIEW Bacteria are the leading cause of infections in solid organ transplant (SOT) recipients, significantly impacting patient outcome. Recently detailed and comprehensive epidemiological data have been published. RECENT FINDING This literature review aims to provide an overview of bacterial infections affecting different types of SOT recipients, emphasizing underlying risk factors and pathophysiological mechanisms. SUMMARY Lung transplantation connects two microbiotas: one derived from the donor's lower respiratory tract with one from the recipient's upper respiratory tract. Similarly, liver transplantation involves a connection to the digestive tract and its microbiota through the bile ducts. For heart transplant recipients, specific factors are related to the management strategies for end-stage heart failure based with different circulatory support tools. Kidney and kidney-pancreas transplant recipients commonly experience asymptomatic bacteriuria, but recent studies have suggested the absence of benefice of routine treatment. Bloodstream infections (BSI) are frequent and affect all SOT recipients. Nonorgan-related risk factors as age, comorbidity index score, and leukopenia contribute to BSI development. Bacterial opportunistic infections have become rare in the presence of efficient prophylaxis. Understanding the epidemiology, risk factors, and pathophysiology of bacterial infections in SOT recipients is crucial for effective management and improved patient outcomes.
Collapse
Affiliation(s)
- Johan Courjon
- Transplant Infectious Diseases Unit, Service of Infectious Diseases, University Hospitals Geneva, Geneva, Switzerland
- Université Côte d'Azur, Inserm, C3M, Nice, France
| | - Dionysios Neofytos
- Transplant Infectious Diseases Unit, Service of Infectious Diseases, University Hospitals Geneva, Geneva, Switzerland
| | - Christian van Delden
- Transplant Infectious Diseases Unit, Service of Infectious Diseases, University Hospitals Geneva, Geneva, Switzerland
| |
Collapse
|
5
|
Voora S, Shah S, Nadim MK. Management of the kidney transplant recipient in the intensive care unit. Curr Opin Crit Care 2023; 29:587-594. [PMID: 37861189 DOI: 10.1097/mcc.0000000000001098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Kidney transplantation is the ideal treatment for patients with chronic kidney disease and end stage renal disease. While centers are performing more transplants every year, the need for organ transplantation outpaces the supply of organ donors. Due to a growing population of patients with advanced kidney disease and a scarcity of kidneys from deceased donors, patients face extended wait times. By the time patients approach transplantation they have multiple comorbidities, in particular cardiovascular complications. Their risk of complications is further compounded by exposure to immunosuppression post kidney transplantation. Kidney transplant recipients (KTRs) are medically complex and may require acute management in the intensive care unit (ICU), as a result of cardiovascular complications, infections, and/or respiratory compromise from lung infections and/or acute pulmonary edema. Acute complication of immunosuppression, such as thrombotic microangiopathy and posterior reversible encephalopathy syndrome may also warrant ICU admission. This review will cover assessment of high-risk complications and management strategies following kidney transplantation. RECENT FINDINGS For intensivists caring for KTRs, it is imperative to understand anatomical considerations of the transplanted kidney, unique infectious risks faced by this population, and appropriate modulation of immunosuppression. SUMMARY Recognizing potential complications and implementing appropriate management strategies for KTRs admitted to the ICU will improve kidney allograft and patient survival outcomes.
Collapse
Affiliation(s)
- Santhi Voora
- Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | | |
Collapse
|
6
|
Budhiraja P, Butterfield R, Gea-Banacloche J, Swaminathan S, Smith ML, Khamash HA, Me HM, Kodali L, Mour GK, Nair S, Misra S, Heilman RL. Outcomes of asymptomatic histologic pyelonephritis of kidney transplant. Clin Transplant 2023; 37:e15125. [PMID: 37705388 DOI: 10.1111/ctr.15125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/10/2023] [Accepted: 09/01/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Urinary Tract Infections are the most common post-transplant infection and can have varied presentations. This study aimed to describe the outcomes of kidney transplant recipients with asymptomatic histologic pyelonephritis on allograft biopsy. Histologic Pyelonephritis was defined as neutrophil cast or neutrophilic tubulitis, interstitial infiltrates with predominant neutrophils, and no evidence of rejection or glomerulonephritis on biopsy. METHODS The study included 123 kidney transplant recipients, of whom 95 underwent protocol biopsies, and 28 had biopsies for elevated creatinine within the first 2 years of a kidney transplant. RESULTS The mean age of the cohort was 55.3 years, with 52% females and 78% deceased donor transplants. The risk factors for asymptomatic histologic pyelonephritis were recipient female sex (OR 1.89, 1.3-2.7, diabetes mellitus (OR 2.479, 1.687-3.645), and deceased donation (OR 1.69, 1.098-2.63). The incidence of asymptomatic pyelonephritis on protocol biopsy was 1.7%, with 52% having positive urine cultures and Escherichia coli being the most common bacteria. Subjects with asymptomatic pyelonephritis had inferior graft survival compared to the matched cohort HR 1.88 (1.06-3.35), p = .0281. In addition, of these 123 subjects, 68 (55%) subsequently developed pyelonephritis, and 34 subjects had pyelonephritis within 6 months after this episode. Subjects with recurrent infections exhibited lower survival HR 2.86 (1.36-6.02) and a trend toward higher rejection risk. CONCLUSION Asymptomatic histologic pyelonephritis can occur in kidney transplant recipients and is associated with inferior graft survival.
Collapse
Affiliation(s)
- Pooja Budhiraja
- Division of Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - Juan Gea-Banacloche
- Department of Clinical Research, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | | | - Maxwell L Smith
- Department of Pathology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Hassan A Khamash
- Division of Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Hay Me Me
- Division of Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Lavanya Kodali
- Division of Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Girish K Mour
- Division of Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Sumi Nair
- Division of Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Suman Misra
- Division of Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | |
Collapse
|
7
|
Fiorentino M, Bagagli F, Deleonardis A, Stasi A, Franzin R, Conserva F, Infante B, Stallone G, Pontrelli P, Gesualdo L. Acute Kidney Injury in Kidney Transplant Patients in Intensive Care Unit: From Pathogenesis to Clinical Management. Biomedicines 2023; 11:1474. [PMID: 37239144 PMCID: PMC10216683 DOI: 10.3390/biomedicines11051474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/05/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
Kidney transplantation is the first-choice treatment for end-stage renal disease (ESRD). Kidney transplant recipients (KTRs) are at higher risk of experiencing a life-threatening event requiring intensive care unit (ICU) admission, mainly in the late post-transplant period (more than 6 months after transplantation). Urosepsis and bloodstream infections account for almost half of ICU admissions in this population; in addition, potential side effects related to immunosuppressive treatment should be accounted for cytotoxic and ischemic changes induced by calcineurin inhibitor (CNI), sirolimus/CNI-induced thrombotic microangiopathy and posterior reversible encephalopathy syndrome. Throughout the ICU stay, Acute Kidney Injury (AKI) incidence is common and ranges from 10% to 80%, and up to 40% will require renal replacement therapy. In-hospital mortality can reach 30% and correlates with acute illness severity and admission diagnosis. Graft survival is subordinated to baseline estimated glomerular filtration rate (eGFR), clinical presentation, disease severity and potential drug nephrotoxicity. The present review aims to define the impact of AKI events on short- and long-term outcomes in KTRs, focusing on the epidemiologic data regarding AKI incidence in this subpopulation; the pathophysiological mechanisms underlying AKI development and potential AKI biomarkers in kidney transplantation, graft and patients' outcomes; the current diagnostic work up and management of AKI; and the modulation of immunosuppression in ICU-admitted KTRs.
Collapse
Affiliation(s)
- Marco Fiorentino
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| | - Francesca Bagagli
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| | - Annamaria Deleonardis
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| | - Alessandra Stasi
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| | - Rossana Franzin
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| | - Francesca Conserva
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| | - Barbara Infante
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, 71122 Foggia, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, 71122 Foggia, Italy
| | - Paola Pontrelli
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| |
Collapse
|
8
|
Kumar R, Pereira M, Taimur S, True K, Detwiler R, van Duin D. Duration of antibiotic treatment for acute graft pyelonephritis: What's the standard of care? Transpl Infect Dis 2023; 25:e13996. [PMID: 36495172 DOI: 10.1111/tid.13996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 10/06/2022] [Accepted: 10/28/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Limited evidence is available to inform the duration of antibiotic treatment in kidney transplant recipients with bacterial acute graft pyelonephritis. Guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation suggest a 14-21 day duration. METHODS A four-question survey was constructed to determine the current standard of practice for the duration of treatment for acute graft pyelonephritis. The survey was distributed among members of the Infectious Diseases and the Kidney Pancreas Communities of Practice of the American Society of Transplantation. RESULTS Among 144 survey respondents, 87 (60%) were infectious disease physicians, and 36 (25%) were transplant nephrologists. Although most (55%) respondents preferred a 14-day duration, a spread between 7 and 28 days was observed. Goals of treatment and drivers for longer duration differed between infectious disease physicians and transplant nephrologists. CONCLUSIONS Although most respondents prefer a 14-day duration of treatment for acute graft pyelonephritis, a wide range of responses was seen between 7 and 28 days. More evidence is needed to inform optimal treatment duration in this common infectious complication after transplantation.
Collapse
Affiliation(s)
- Rebecca Kumar
- Division of Infectious Diseases, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Marcus Pereira
- Division of Infectious Diseases, Columbia University, New York, New York, USA
| | - Sarah Taimur
- Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Karin True
- Division of Nephrology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Randall Detwiler
- Division of Nephrology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina, USA
| |
Collapse
|
9
|
Risk Factors and Outcomes of Acute Graft Pyelonephritis with Bacteremia Due to Multidrug-Resistant Gram-Negative Bacilli among Kidney Transplant Recipients. J Clin Med 2022; 11:jcm11113165. [PMID: 35683553 PMCID: PMC9181603 DOI: 10.3390/jcm11113165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/25/2022] [Accepted: 05/31/2022] [Indexed: 02/05/2023] Open
Abstract
Acute graft pyelonephritis (AGP) is the leading cause of bloodstream infection in kidney transplant (KT) recipients. The prevalence of urinary tract infections caused by multidrug-resistant (MDR) Gram-negative bacilli is increasing. This 14-year prospective observational study sought to determine the clinical characteristics, risk factors, and outcomes of AGP with bacteremia due to MDR Gram-negative bacilli. Overall, 278 episodes of AGP with bacteremia due to MDR Gram-negative and non-MDR Gram-negative bacilli were identified and compared in 214 KT recipients; MDR Gram-negative bacilli were the cause in 28.4%. Overall 30-day mortality was low (1.1%). Risk factors independently associated with AGP due to MDR Gram-negative bacilli were male sex (OR 3.08; 95%CI 1.60–5.93), previous episode of bacteremic AGP (OR 2.11, 95%CI 1.09–4.09), prior antibiotic therapy in the preceding month (OR 2.47, 95%CI 1.33–4.57), and nosocomial acquisition (OR 2.03, 95%CI 1.14–3.62). Forty-three percent of MDR Gram-negative episodes received inappropriate empirical antibiotic therapy. The risk factors identified in this study may help physicians when selecting empirical antibiotic treatment for AGP. Previous antibiotic use was the main modifiable factor. Its presence highlights the importance of avoiding unnecessary antibiotics in order to bring down the high rates of MDR Gram-negative bacilli infections in this population.
Collapse
|
10
|
Bacterial and Viral Infection and Sepsis in Kidney Transplanted Patients. Biomedicines 2022; 10:biomedicines10030701. [PMID: 35327510 PMCID: PMC8944970 DOI: 10.3390/biomedicines10030701] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 02/05/2023] Open
Abstract
Kidney transplanted patients are a unique population with intrinsic susceptibility to viral and bacterial infections, mainly (but not exclusively) due to continuous immunosuppression. In this setting, infectious episodes remain among the most important causes of death, with different risks according to the degree of immunosuppression, time after transplantation, type of infection, and patient conditions. Prevention, early diagnosis, and appropriate therapy are the goals of infective management, taking into account that some specific characteristics of transplanted patients may cause a delay (the absence of fever or inflammatory symptoms, the negativity of serological tests commonly adopted for the general population, or the atypical anatomical presentation depending on the surgical site and graft implantation). This review considers the recent available findings of the most common viral and bacterial infection in kidney transplanted patients and explores risk factors and outcomes in septic evolution.
Collapse
|
11
|
Ronsin C, Chaba A, Suchanek O, Coindre JP, Kerleau C, Garandeau C, Houzet A, Cantarovich D, Dantal J, Blancho G, Giral M, Couvrat-Desvergnes G, Ville S. Incidence, risk factors and outcomes of kidney and liver cyst infection in kidney transplant recipient with autosomal dominant polycystic kidney disease. Kidney Int Rep 2022; 7:867-875. [PMID: 35497795 PMCID: PMC9039903 DOI: 10.1016/j.ekir.2022.01.1062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/12/2022] [Accepted: 01/24/2022] [Indexed: 12/11/2022] Open
Abstract
Introduction Methods Results Conclusion
Collapse
|