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Casalini G, Giacomelli A, Antinori S. The WHO fungal priority pathogens list: a crucial reappraisal to review the prioritisation. THE LANCET. MICROBE 2024; 5:717-724. [PMID: 38608682 DOI: 10.1016/s2666-5247(24)00042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 02/01/2024] [Accepted: 02/06/2024] [Indexed: 04/14/2024]
Abstract
In October, 2022, WHO published the first fungal priority pathogen list, which categorised 19 fungal entities into three priority groups (critical, high, and medium), for prioritisation of research efforts. The final ranking was determined via multiple criteria decision analysis, considering both research and development needs and perceived public health importance. In this Personal View, we discuss the positioning of the fungal pathogens, namely, Mucorales, Candida spp, Histoplasma spp, Coccidioides and Paracoccidioides spp, Fusarium spp, eumycetoma causative agents, Talaromyces marneffei, and Pneumocystis jirovecii, while expressing concerns about potential disparities between the WHO fungal priority pathogen list ranking and the actual disease burden associated with these pathogens. Finally, we propose a revised prioritisation list that also considers the regional disparities in the burden of fungal diseases.
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Affiliation(s)
- Giacomo Casalini
- Department of Biomedical and Clinical Sciences, DIBIC, Università degli Studi di Milano, Milan, Italy; III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, Milan, Italy
| | - Andrea Giacomelli
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, Milan, Italy
| | - Spinello Antinori
- Department of Biomedical and Clinical Sciences, DIBIC, Università degli Studi di Milano, Milan, Italy; III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, Milan, Italy.
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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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Esnault V, Hoisnard L, Peiffer B, Fihman V, Fourati S, Angebault C, Champy C, Gallien S, Attias P, Morel A, Grimbert P, Melica G, Matignon M. Beyond the First Year: Epidemiology and Management of Late-Onset Opportunistic Infections After Kidney Transplantation. Transpl Int 2024; 37:12065. [PMID: 38468638 PMCID: PMC10926380 DOI: 10.3389/ti.2024.12065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 02/13/2024] [Indexed: 03/13/2024]
Abstract
Late opportunistic infections (OI) occurring beyond the first year after kidney transplantation (KT) are poorly described and not targeted by prophylactic strategies. We performed a ten-year retrospective monocentric cohort study describing epidemiology, risk factors and impact of late OI occurring 1 year after KT. We included clinically symptomatic OI requiring treatment besides BK virus nephropathy. Control groups included early OI occurring in the first year after KT, and KT recipients without OI since KT and alive with a functional allograft at 1 year. Among 1066 KT recipients, 185 (19.4%) presented a first episode of OI 21.0 (8.0-45.0) months after KT: 120 late OI (64.9%) and 65 early OI (35.1%). Late OI were mainly viral (N = 83, 69.2%), mostly herpes zoster (HZ) (N = 36, 43.4%). Pneumocystis represented most late fungal infections (N = 12/25, 48%). Compared to early OI, we reported more pneumocystis (p = 0.002) and less invasive aspergillosis (p = 0.01) among late OI. Patients with late OI were significatively younger at KT (54.0 ± 13.3 vs. 60.2 ± 14.3 years, p = 0.05). Patient and allograft survival rates between late OI and control groups were similar. Only age was independently associated with mortality. While late OI were not associated with higher mortality or graft loss, implementing prophylactic strategies might prevent such infections.
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Affiliation(s)
- V. Esnault
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Maladies Infectieuses et d’Immunologie Clinique, Centre Hospitalo-Universitaire (CHU) Henri Mondor, Créteil, France
| | - L. Hoisnard
- Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, AP-HP, Henri Mondor Hospital, Créteil, France
- INSERM, Centre d’Investigation Clinique 1430, Créteil, France
- EpiDermE Epidemiology in Dermatology and Evaluation of Therapeutics, EA7379, Paris Est Créteil University UPEC, Créteil, France
| | - B. Peiffer
- AP-HP, Département Médico-Universitaire Médecine, CHU Henri Mondor, Créteil, France
| | - V. Fihman
- AP-HP, Service de Microbiologie, Département de Prévention, Diagnostic et Traitement des Infections, CHU Henri Mondor, Créteil, France
| | - S. Fourati
- AP-HP, Service de Microbiologie, Département de Prévention, Diagnostic et Traitement des Infections, CHU Henri Mondor, Créteil, France
| | - C. Angebault
- AP-HP, Service de Microbiologie, Département de Prévention, Diagnostic et Traitement des Infections, CHU Henri Mondor, Créteil, France
- EA DYNAMiC 7380, Faculté de Santé, University Paris-Est Créteil (UPEC), Ecole Nationale Vétérinaire d’Alfort (ENVA), USC Anses, Créteil, France
| | - C. Champy
- AP-HP, Service d’Urologie, CHU Henri Mondor, Créteil, France
| | - S. Gallien
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Maladies Infectieuses et d’Immunologie Clinique, Centre Hospitalo-Universitaire (CHU) Henri Mondor, Créteil, France
- EA DYNAMiC 7380, Faculté de Santé, University Paris-Est Créteil (UPEC), Ecole Nationale Vétérinaire d’Alfort (ENVA), USC Anses, Créteil, France
| | - P. Attias
- AP-HP, Service de Néphrologie et de Transplantation Rénale, Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », CHU Henri Mondor, Créteil, France
| | - A. Morel
- AP-HP, Service de Néphrologie et de Transplantation Rénale, Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », CHU Henri Mondor, Créteil, France
| | - P. Grimbert
- AP-HP, Service de Néphrologie et de Transplantation Rénale, Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », CHU Henri Mondor, Créteil, France
- University of Paris-Est-Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Team 21, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - G. Melica
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Maladies Infectieuses et d’Immunologie Clinique, Centre Hospitalo-Universitaire (CHU) Henri Mondor, Créteil, France
| | - M. Matignon
- AP-HP, Service de Néphrologie et de Transplantation Rénale, Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », CHU Henri Mondor, Créteil, France
- University of Paris-Est-Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Team 21, Institut Mondor de Recherche Biomédicale, Créteil, France
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Passerini M, Nayfeh T, Yetmar ZA, Coussement J, Goodlet KJ, Lebeaux D, Gori A, Mahmood M, Temesgen Z, Murad MH. Trimethoprim-sulfamethoxazole significantly reduces the risk of nocardiosis in solid organ transplant recipients: systematic review and individual patient data meta-analysis. Clin Microbiol Infect 2024; 30:170-177. [PMID: 37865337 DOI: 10.1016/j.cmi.2023.10.008] [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: 08/14/2023] [Revised: 10/06/2023] [Accepted: 10/08/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Whether trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis prevents nocardiosis in solid organ transplant (SOT) recipients is controversial. OBJECTIVES To assess the effect of TMP-SMX in the prevention of nocardiosis after SOT, its dose-response relationship, its effect on preventing disseminated nocardiosis, and the risk of TMP-SMX resistance in case of breakthrough infection. METHODS A systematic review and individual patient data meta-analysis. DATA SOURCES MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Web of Science Core Collection, and Scopus up to 19 September 2023. STUDY ELIGIBILITY CRITERIA (a) Risk of nocardiosis between SOT recipients with and without TMP-SMX prophylaxis, or (b) sufficient details to determine the rate of TMP-SMX resistance in breakthrough nocardiosis. PARTICIPANTS SOT recipients. INTERVENTION TMP-SMX prophylaxis versus no prophylaxis. ASSESSMENT OF RISK OF BIAS Risk Of Bias In Non-randomized Studies-of Exposure (ROBINS-E) for comparative studies; dedicated tool for non-comparative studies. METHODS OF DATA SYNTHESIS For our primary outcome (i.e. to determine the effect of TMP-SMX on the risk of nocardiosis), a one-step mixed-effects regression model was used to estimate the association between the outcome and the exposure. Univariate and multivariable unconditional regression models were used to adjust for the potential confounding effects. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS Individual data from three case-control studies were obtained (260 SOT recipients with nocardiosis and 519 uninfected controls). TMP-SMX prophylaxis was independently associated with a significantly decreased risk of nocardiosis (adjusted OR = 0.3, 95% CI 0.18-0.52, moderate certainty of evidence). Variables independently associated with an increased risk of nocardiosis were older age, current use of corticosteroids, high calcineurin inhibitor concentration, recent acute rejection, lower lymphocyte count, and heart transplant. Breakthrough infections (66/260, 25%) were generally susceptible to TMP-SMX (pooled proportion 98%, 95% CI 92-100). CONCLUSIONS In SOT recipients, TMP-SMX prophylaxis likely reduces the risk of nocardiosis. Resistance appears uncommon in case of breakthrough infection.
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Affiliation(s)
- Matteo Passerini
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy; Department of Infectious Disease, ASST FBF SACCO Fatebenefratelli, Milan, Lombardia, Italy.
| | - Tarek Nayfeh
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Zachary A Yetmar
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Department of Infectious Diseases, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Julien Coussement
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia; Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Guadeloupe, Les Abymes, Guadeloupe, France
| | - Kellie J Goodlet
- Department of Pharmacy Practice, Midwestern University, Glendale, AZ, USA; Norton Thoracic Institute, Dignity Health - St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - David Lebeaux
- Institut Pasteur, Université Paris Cité, CNRS UMR 6047, Genetics of Biofilms Laboratory, Paris, France; Département de Maladies Infectieuses et Tropicales, AP-HP, Hôpital Saint-Louis, Lariboisière, Paris, France
| | - Andrea Gori
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy; Department of Infectious Disease, ASST FBF SACCO Fatebenefratelli, Milan, Lombardia, Italy; Centre for Multidisciplinary Research in Health Science (MACH), University of Milan, Milan, Italy
| | - Maryam Mahmood
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Zelalem Temesgen
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mohammad H Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Eberl I, Binquet C, Guilloteau A, Legendre M, Dalle F, Piroth L, Tinel C, Blot M. CMV Infection and Lymphopenia: Warning Markers of Pneumocystis Pneumonia in Kidney Transplant Recipients. Transpl Int 2024; 37:12192. [PMID: 38328616 PMCID: PMC10849047 DOI: 10.3389/ti.2024.12192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/11/2024] [Indexed: 02/09/2024]
Abstract
Pneumocystis pneumonia (PcP) remains life-threatening in kidney transplant recipients (KTR). Our study investigated risk factors one-year before PcP. We conducted a monocentric, case-control study including all KTR at the Dijon University Hospital (France) with a diagnosis of PcP between 2005 and 2022 (cases), and matched control KTR with no history of PcP (3 controls/case). Among all 1,135 KTR, 57 cases (5%) and 169 matched-controls were included. PcP was associated with 18% mortality. Compared to controls, cases were older, with a higher immunological risk, and CMV infection was more frequent in the year preceding the occurrence of PcP (23% vs. 4%; p < 0.001). As early as 1 year before PcP, lymphocyte counts were lower and serum creatinine levels were higher in cases, but immunosuppressive regimens were not significantly different. Multivariable analysis identified lymphocyte count, serum creatinine level, being treated by immunosuppressive therapy other than anti-rejection drugs, and CMV infection in the year preceding the time PcP as independently associated with the occurrence of PcP. PcP was associated with an increased risk of subsequent chronic rejection (27% vs. 3%; p = 0.001) and return to dialysis (20% vs. 3%; p = 0.002). The occurrence of CMV infection and a low lymphocyte count could redefine the indications for continuation or reinitiation of anti-Pneumocystis prophylaxis.
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Affiliation(s)
- Isabelle Eberl
- Department of Infectious Diseases, Dijon-Bourgogne University Hospital, Dijon, France
| | - Christine Binquet
- CHU Dijon-Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- LabEx LipSTIC, University of Burgundy, Dijon, France
| | - Adrien Guilloteau
- Côte d´Or Haematological Malignancy Registry (RHEMCO), Dijon-Bourgogne University Hospital, Dijon, France
| | - Mathieu Legendre
- Department Nephrology and Kidney Transplantation, Dijon-Bourgogne University Hospital, Dijon, France
| | - Frederic Dalle
- Department of Parasitology-Mycology, Dijon Bourgogne University Hospital, Dijon, France
- UMR PAM Université de Bourgogne Franche-Comté (UBFC), AgroSup Dijon, Équipe Vin, Aliment, Microbiologie, Stress, Groupe Interactions Candida-muqueuses, Dijon, France
| | - Lionel Piroth
- Department of Infectious Diseases, Dijon-Bourgogne University Hospital, Dijon, France
- CHU Dijon-Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- LabEx LipSTIC, University of Burgundy, Dijon, France
| | - Claire Tinel
- Department Nephrology and Kidney Transplantation, Dijon-Bourgogne University Hospital, Dijon, France
- Université Bourgogne Franche-Comté (UBFC), EFS BFC, Inserm UMR1098, RIGHT, Besançon, France
| | - Mathieu Blot
- Department of Infectious Diseases, Dijon-Bourgogne University Hospital, Dijon, France
- CHU Dijon-Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- LabEx LipSTIC, University of Burgundy, Dijon, France
- Lipness Team, INSERM Research Centre LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France
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Zhu X, Xie M, Fan J, Geng B, Fei G, Zhou Q, Wu H, Liu X, Jiang X. Clinical characteristics and risk factors for late-onset pneumocystis jirovecii pneumonia in kidney transplantation recipients. Mycoses 2024; 67:e13688. [PMID: 38214337 DOI: 10.1111/myc.13688] [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: 08/29/2023] [Revised: 12/09/2023] [Accepted: 12/14/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is a common and troublesome complication of kidney transplantation. In the era of prophylaxis, the peak incidence of PJP after kidney transplantation and specific characteristics of late-onset PJP have always been debated. METHODS We performed a retrospective study by analysing the data of post-transplantation pneumonia in adult kidney transplantation recipients between March 2014 and December 2021 in The Affiliated First Hospital of University of Science and Technology of China (USTC). A total of 361 patients were included and divided into early-onset PJP, late-onset PJP and non-PJP groups. The characteristics of each group and related risk factors for the late-onset patients were investigated. RESULTS Some patients developed PJP 9 months later with a second higher occurrence between month 10 and 15 after transplantation. Compared with non-PJP, ABO-incompatible and cytomegalovirus (CMV) viremia were significantly associated with late onset of PJP in multivariate analysis. The use of tacrolimus, CMV viremia, elevated CD8(+) T cell percent and hypoalbuminemia were risk factors for late PJP. Receiver operating characteristic curve analysis demonstrated that a combination of those factors could increase the sensitivity of prediction remarkably, with an area under the curve of 0.82, a sensitivity of 80% and a specificity of 83%. CONCLUSIONS PJP could occur months after kidney transplantation. ABO-incompatible transplant recipients are at high risk of PJP. In the later stages of transplantation, CMV viremia, T lymphocyte subsets percentage and serum albumin levels should be monitored in patients using tacrolimus.
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Affiliation(s)
- Xiaofeng Zhu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Department of Pulmonary Medicine, School of Clinical Medicine, Bengbu Medical College, Bengbu, China
| | - Mengshu Xie
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Department of Pulmonary Medicine, School of Clinical Medicine, Bengbu Medical College, Bengbu, China
| | - Jiaqi Fan
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Bei Geng
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Guangru Fei
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Qianqian Zhou
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Huimei Wu
- Anhui Geriatric Institute, Department of Geriatric Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xuehan Liu
- Core Facility Center for Medical Sciences, The First Affiliated Hospital of USTC, Hefei, China
| | - Xuqin Jiang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
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Li G, Ji D, Chang Y, Tang Z, Cheng D. Successful management of concurrent COVID-19 and Pneumocystis Jirovecii Pneumonia in kidney transplant recipients: a case series. BMC Pulm Med 2023; 23:458. [PMID: 37990199 PMCID: PMC10664536 DOI: 10.1186/s12890-023-02764-2] [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: 10/03/2023] [Accepted: 11/15/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Pneumocystis pneumonia (PCP) is a life-threatening pulmonary fungal infection that predominantly affects immunocompromised individuals, including kidney transplant recipients. Recent years have witnessed a rising incidence of PCP in this vulnerable population, leading to graft loss and increased mortality. Immunosuppression, which is essential in transplant recipients, heightens susceptibility to viral and opportunistic infections, magnifying the clinical challenge. Concurrently, the global impact of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been profound. Kidney transplant recipients have faced severe outcomes when infected with SARS-CoV-2, often requiring intensive care. Co-infection with COVID-19 and PCP in this context represents a complex clinical scenario that requires precise management strategies, involving a delicate balance between immunosuppression and immune activation. Although there have been case reports on management of COVID-19 and PCP in kidney transplant recipients, guidance on how to tackle these infections when they occur concurrently remains limited. CASE PRESENTATIONS We have encountered four kidney transplant recipients with concurrent COVID-19 and PCP infection. These patients received comprehensive treatment that included adjustment of their maintenance immunosuppressive regimen, anti-pneumocystis therapy, treatment for COVID-19 and other infections, and symptomatic and supportive care. After this multifaceted treatment strategy, all of these patients improved significantly and had favorable outcomes. CONCLUSIONS We have successfully managed four kidney transplant recipients co-infected with COVID-19 and PCP. While PCP is a known complication of immunosuppressive therapy, its incidence in patients with COVID-19 highlights the complexity of dual infections. Our findings suggest that tailored immunosuppressive regimens, coupled with antiviral and antimicrobial therapies, can lead to clinical improvement in such cases. Further research is needed to refine risk assessment and therapeutic strategies, which will ultimately enhance the care of this vulnerable population.
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Affiliation(s)
- Guoping Li
- Department of Nephrology, Nanjing Yimin Hospital, Nanjing, 211100, China
| | - Daxi Ji
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 200016, China
| | - Youcheng Chang
- Department of Nephrology, Nanjing Yimin Hospital, Nanjing, 211100, China
| | - Zheng Tang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 200016, China
| | - Dongrui Cheng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 200016, China.
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Navarro M, Allemang-Trivalle A, Leducq S, Jonville-Bera AP, Maurier A, Zejli T, Edée AE, Harchaoui E, Giraudeau B, Maruani A. Indication for a Pneumocystis Prophylaxis Therapy in Patients with Vascular Anomalies Treated with PIK3/AKT/mTOR Pathway Inhibitors: Experts' Opinion and Systematic Review from the Literature. Dermatology 2023; 239:942-951. [PMID: 37793356 DOI: 10.1159/000533675] [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: 11/23/2022] [Accepted: 08/14/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Vascular anomalies (VAs) are increasingly being treated with PI3K/AKT/mTOR pathway inhibitors. These drugs have immunosuppressive properties and thus theoretically overexpose patients to opportunistic infections, especially Pneumocystis jirovecii pneumonia (PJP). PJP prophylaxis use lacks consensus. We aimed to investigate the prevalence of PJP in patients receiving mTOR/PI3K/AKT inhibitors for VAs and determine any indication for pneumocystis prophylaxis in this population. METHODS The study was conducted in 2 parts: (1) we sent a survey to a panel of international experts of VAs asking about their use of pneumocystis prophylaxis drugs and (2) we performed a systematic review of the literature of all published cases of patients receiving these drugs for VA to estimate the prevalence of PJP in this population. RESULTS Answers from 68 experts were analyzed: 21 (30.9%) answered they always add PJP prophylaxis when prescribing mTOR inhibitors, 20 (29.4%) case-by-case, and 27 (39.7%) never. For the systematic review, among 3,053 reports screened, 217 were included involving 1,189 patients (1,143 received sirolimus, 38 everolimus, 4 alpelisib, 4 miransertib). Among the 1,189 cases, 2 (0.2%) PJP were reported: one under sirolimus and one under everolimus. Thus, the prevalence of PJP was estimated at 0.88 cases/1,000 patients under sirolimus (95% CI: -0.84 to 2.59) and 26.31 cases/1,000 under everolimus (95% CI: -24.58 to 77.18). Patients with PJP never received prophylaxis drugs. We found no PJP cases under alpelisib and miransertib. PJP prophylaxis was given in 218 (18.3%) cases, more frequently for children (91.3 vs. 77.2% in the non-prophylaxis group, p = 0.012), mostly trimethoprim-sulfamethoxazole (186 patients, 85.3%). CONCLUSION Our study shows that even if PJP is a rare event, it may occur in patients with VAs treated with an mTOR inhibitor. Although our results cannot allow for revising guidelines, prophylaxis with TMP-SMX might be appropriate for a subgroup of patients with risk factors for PJP.
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Affiliation(s)
- Maxime Navarro
- CHRU Tours, Department of Dermatology, Unit of Pediatric dermatology, Tours, France
- Reference Center for Genodermatoses and Rare Skin Diseases (MAGEC-Tours), Tours, France
| | | | - Sophie Leducq
- CHRU Tours, Department of Dermatology, Unit of Pediatric dermatology, Tours, France
- Reference Center for Genodermatoses and Rare Skin Diseases (MAGEC-Tours), Tours, France
- University of Tours, University of Nantes, INSERM 1246-SPHERE, Tours, France
| | - Annie-Pierre Jonville-Bera
- University of Tours, University of Nantes, INSERM 1246-SPHERE, Tours, France
- CHRU Tours, Department of Clinical Pharmacology, Regional Pharmacovigilance Center, Tours, France
| | - Anaïs Maurier
- CHRU Tours, Department of Clinical Pharmacology, Regional Pharmacovigilance Center, Tours, France
| | - Tarik Zejli
- CHRU Tours, Clinical Investigation Center of Tours, INSERM 1415, Bretonneau Hospital, Tours, France
| | - Afi-Emiliène Edée
- Reference Center for Genodermatoses and Rare Skin Diseases (MAGEC-Tours), Tours, France
| | - Emilie Harchaoui
- CHRU Tours, Department of Dermatology, Unit of Pediatric dermatology, Tours, France
- University of Tours, University of Nantes, INSERM 1246-SPHERE, Tours, France
| | - Bruno Giraudeau
- University of Tours, University of Nantes, INSERM 1246-SPHERE, Tours, France
- CHRU Tours, Clinical Investigation Center of Tours, INSERM 1415, Bretonneau Hospital, Tours, France
| | - Annabel Maruani
- CHRU Tours, Department of Dermatology, Unit of Pediatric dermatology, Tours, France
- Reference Center for Genodermatoses and Rare Skin Diseases (MAGEC-Tours), Tours, France
- University of Tours, University of Nantes, INSERM 1246-SPHERE, Tours, France
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9
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Yetmar ZA, Duffy D, Smith BH, Vikram HR, Brumble L, Limper AH, Beam E. Risk factors and outcomes of Pneumocystis pneumonia in solid organ transplant recipients: Impact of posttransplant lymphoproliferative disorder. Clin Transplant 2023; 37:e15021. [PMID: 37195184 PMCID: PMC10524515 DOI: 10.1111/ctr.15021] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/24/2023] [Accepted: 05/06/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is a potentially fatal infection afflicting the immunocompromised population, including solid organ transplant (SOT) recipients. Several risk factors have been described; however, little is known regarding the risk of PJP in SOT recipients with posttransplant lymphoproliferative disorder (PTLD). METHODS We performed a nested case-control study of SOT recipients diagnosed with PJP from 2000 to 2020. PJP was defined as positive microscopy or polymerase chain reaction testing with compatible symptoms and radiographic findings. Control patients were matched 2:1 by year of first transplant, first transplanted organ, transplant center, and sex. Multivariable conditional logistic regression was performed to test associations with PJP and Cox regression analyzed post-PJP outcomes. RESULTS Sixty-seven PJP cases were matched to 134 controls. The most common transplant was kidney (55.2%). Fourteen patients had a history of PTLD, 12 of whom developed PJP. After adjusting for age, acute rejection, cytomegalovirus infection, PJP prophylaxis, and lymphopenia (lymphocyte count < .5 × 109 /L), PTLD was independently associated with PJP (OR 14.0, 95% CI 1.7-114.5; p = .014). Lymphopenia was also a significant association (OR 8.2, 95% CI 3.2-20.7; p < .001). PJP was associated with mortality within 90 days of diagnosis (p < .001), but not after 90 days (p = .317). PJP was also associated with 90-day death-censored renal allograft loss (p = .026). CONCLUSIONS PTLD is independently associated with PJP after adjustment for recognized risk factors. This is likely influenced by PTLD-directed chemotherapy, particularly rituximab-containing regimens. PJP is associated with early mortality, but this effect is not persistent after 90 days. PJP prophylaxis should be considered in SOT recipients with PTLD.
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Affiliation(s)
- Zachary A. Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Dustin Duffy
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Byron H. Smith
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | | | - Lisa Brumble
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, FL, USA
| | - Andrew H. Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elena Beam
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
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10
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Trubin PA, Azar MM. Current Concepts in the Diagnosis and Management of Pneumocystis Pneumonia in Solid Organ Transplantation. Infect Dis Clin North Am 2023:S0891-5520(23)00026-0. [PMID: 37142510 DOI: 10.1016/j.idc.2023.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Pneumocystis infection manifests predominantly as an interstitial pneumonia in immunocompromised patients. Diagnostic testing in the appropriate clinical context can be highly sensitive and specific and involves radiographic imaging, fungal biomarkers, nucleic acid amplification, histopathology, and lung fluid or tissue sampling. Trimethoprim-sulfamethoxazole remains the first-choice agent for treatment and prophylaxis. Investigation continues to promote a deeper understanding of the pathogen's ecology, epidemiology, host susceptibility, and optimal treatment and prevention strategies in solid organ transplant recipients.
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Affiliation(s)
- Paul A Trubin
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, 135 College Street, New Haven, CT 06510, USA.
| | - Marwan M Azar
- Department of Medicine, Section of Infectious Diseases; Department of Laboratory Medicine; Yale School of Medicine, 135 College Street, New Haven, CT 06510, USA
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11
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Hänsel L, Schumacher J, Denis B, Hamane S, Cornely OA, Koehler P. How to diagnose and treat a non-HIV patient with Pneumocystis jirovecii pneumonia (PCP)? Clin Microbiol Infect 2023:S1198-743X(23)00186-6. [PMID: 37086781 DOI: 10.1016/j.cmi.2023.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Pneumocystis jirovecii Pneumonia (PCP) incidence is increasing in non-HIV infected patients. In contrast to PCP in patients infected with HIV, diagnosis is often delayed, and illness is associated with an increased mortality. OBJECTIVE To provide a comprehensive review of clinical presentation, risk factors, diagnostic strategies, and treatment options of PCP in non-HIV-infected patients. SOURCES Web-based literature review on PCP for trials, meta-analyses and systematic reviews using PubMed. Restriction to English language was applied. CONTENT Common underlying conditions in non-HIV-infected patients with PCP are haematological malignancies, autoimmune and inflammatory diseases, solid organ or haematopoietic stem cell transplant and prior exposure to corticosteroids. New risk groups include patients receiving monoclonal antibodies and immunomodulating therapies. Non-HIV-infected patients with PCP present with rapid onset and progression of pneumonia, increased duration of hospitalization and a significantly higher mortality rate than patients infected with HIV. PCP is diagnosed by a combination of clinical symptoms, radiological and mycological features. Immunofluorescence microscopy from bronchoalveolar lavage (BAL) or PCR testing CT imaging and evaluation of the clinical presentation are required. The established treatment regime consists of trimethoprim and sulfamethoxazole. IMPLICATIONS While the number of patients immunosuppressed for other causes than HIV is increasing, a simultaneous rise in PCP incidence is observed. In the group of non-HIV-infected patients, a rapid onset of symptoms, a more complex course, and a higher mortality rate are recorded. Therefore, time to diagnosis must be as short as possible to initiate effective therapy promptly. This review aims to raise awareness of PCP in an increasingly affected at-risk group and provide clinicians with a practical guide for efficient diagnosis and targeted therapy. Furthermore, it intends to display current inadequacies in research on the topic of PCP.
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Affiliation(s)
- Luise Hänsel
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany
| | - Jana Schumacher
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany
| | - Blandine Denis
- Department of infectious diseases, Saint Louis and Lariboisière Hospitals, APHP, Paris, France, Excellence Centre for Medical Mycology (ECMM), Paris, France
| | - Samia Hamane
- Department of infectious diseases, Saint Louis and Lariboisière Hospitals, APHP, Paris, France, Excellence Centre for Medical Mycology (ECMM), Paris, France
| | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany
| | - Philipp Koehler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany.
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12
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Lussac-Sorton F, Fleur T, Voisin T, Issa N, Blanchard É, Charpentier É, Delhaes L. Interest of a Commercialized Pneumocystis jirovecii Quantitative PCR to Discriminate Colonization from Pneumocystis Pneumonia according to the Revised EORTC/MSGERC Criteria. J Clin Med 2022; 12:jcm12010316. [PMID: 36615116 PMCID: PMC9821677 DOI: 10.3390/jcm12010316] [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: 12/01/2022] [Revised: 12/25/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023] Open
Abstract
Quantitative PCR (qPCR) is highly sensitive to diagnose Pneumocystis jirovecii (Pj) pneumonia (PCP). However, differentiating PCP and colonization remains difficult. This study aimed to establish the performances of the commercialized qPCR MycoGENIE® Pj kit (Ademtech) to distinguish PCP and Pj colonization. Patients with a positive Pj qPCR on bronchoalveolar lavage (BAL) or upper respiratory tract (URT) samples were prospectively included between May 2019 and December 2020 at Bordeaux University Hospital. They were classified in “PCP” or “Pj colonization” groups based on the revised EORTC/MSGERC criteria. The two groups’ results were compared; ROC curves were produced to determine the best thresholds. Excluding the low number of HIV-positive subjects, there were 100 PCP (32 BAL, 68 URT) and 70 Pj colonization (34 BAL, 36 URT). Pj loads were significantly higher in PCP compared to Pj colonization group (p ≤ 0.01). The best cut-offs for PCP diagnosis were 31.45 Cq/8275 copies/mL for BAL and 32.33 Cq/8130 copies/mL for URT (sensitivity = 59.4%, 63.3%, specificity = 82.4%, 88.9%, respectively). Fungal load quantification using MycoGENIE® Pj qPCR helps discriminating PCP from colonization, high fungal loads being indicative of probable PCP. Low load results should be interpreted with caution, in accordance with clinical and radiological signs.
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Affiliation(s)
- Florian Lussac-Sorton
- Service de Parasitologie-Mycologie, Groupe Hospitalier Pellegrin, CHU de Bordeaux, 33000 Bordeaux, France
- Correspondence:
| | - Tara Fleur
- Service de Parasitologie-Mycologie, Groupe Hospitalier Pellegrin, CHU de Bordeaux, 33000 Bordeaux, France
| | - Thibault Voisin
- Service de Parasitologie-Mycologie, Groupe Hospitalier Pellegrin, CHU de Bordeaux, 33000 Bordeaux, France
- Eurofins, Polyclinique Bordeaux Nord, 18 Rue Henri Guillemin, 33300 Bordeaux, France
| | - Nahéma Issa
- Réanimation Médicale, Groupe Hospitalier Saint-André, CHU de Bordeaux, 33000 Bordeaux, France
| | - Élodie Blanchard
- Service de Pneumologie, Hôpital Haut-Lévêque, Groupe Hospitalier Sud, CHU de Bordeaux, 33600 Pessac, France
| | - Éléna Charpentier
- Service de Parasitologie-Mycologie, Groupe Hospitalier Pellegrin, CHU de Bordeaux, 33000 Bordeaux, France
| | - Laurence Delhaes
- Service de Parasitologie-Mycologie, Groupe Hospitalier Pellegrin, CHU de Bordeaux, 33000 Bordeaux, France
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13
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Bromley K, Phillips J, Irish A. Hypercalcaemia in an immunocompromised patient: consider
Pneumocystis jirovecii
pneumonia. Med J Aust 2022; 217:517-518. [DOI: 10.5694/mja2.51761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 03/30/2022] [Accepted: 04/21/2022] [Indexed: 11/11/2022]
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14
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Alsayed AR, Al-Dulaimi A, Alkhatib M, Al Maqbali M, Al-Najjar MAA, Al-Rshaidat MMD. A comprehensive clinical guide for Pneumocystis jirovecii pneumonia: a missing therapeutic target in HIV-uninfected patients. Expert Rev Respir Med 2022; 16:1167-1190. [PMID: 36440485 DOI: 10.1080/17476348.2022.2152332] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Pneumocystis jirovecii is an opportunistic, human-specific fungus that causes Pneumocystis pneumonia (PCP). PCP symptoms are nonspecific. A patient with P. jirovecii and another lung infection faces a diagnostic challenge. It may be difficult to determine which of these agents is responsible for the clinical symptoms, preventing effective treatment. Diagnostic and treatment efforts have been made more difficult by the rising frequency with which coronavirus 2019 (COVID-19) and PCP co-occur. AREAS COVERED Herein, we provide a comprehensive review of clinical and pharmacological recommendations along with a literature review of PCP in immunocompromised patients focusing on HIV-uninfected patients. EXPERT OPINION PCP may be masked by identifying co-existing pathogens that are not necessarily responsible for the observed infection. Patients with severe form COVID-19 should be examined for underlying immunodeficiency, and co-infections must be considered as co-infection with P. jirovecii may worsen COVID-19's severity and fatality. PCP should be investigated in patients with PCP risk factors who come with pneumonia and suggestive radiographic symptoms but have not previously received PCP prophylaxis. PCP prophylaxis should be explored in individuals with various conditions that impair the immune system, depending on their PCP risk.
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Affiliation(s)
- Ahmad R Alsayed
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Abdullah Al-Dulaimi
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Mohammad Alkhatib
- Department of Experimental Medicine, University of Rome "Tor Vergata", Roma, Italy
| | - Mohammed Al Maqbali
- Department of Nursing Midwifery and Health, Northumbria University, Newcastle-Upon-Tyne, UK
| | - Mohammad A A Al-Najjar
- Department of Pharmaceutical Sciences and Pharmaceutics, Applied Science Private University, Amman, Kingdom of Jordan
| | - Mamoon M D Al-Rshaidat
- Laboratory for Molecular and Microbial Ecology (LaMME), Department of Biological Sciences, School of Sciences, The University of Jordan, Amman, Jordan
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15
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Comparison of early and late Pneumocystis jirovecii Pneumonia in kidney transplant patients: the Korean Organ Transplantation Registry (KOTRY) Study. Sci Rep 2022; 12:10682. [PMID: 35739203 PMCID: PMC9226063 DOI: 10.1038/s41598-022-14580-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/09/2022] [Indexed: 11/09/2022] Open
Abstract
Late Pneumocystis jirovecii pneumonia (PJP) is not rare in the era of universal prophylaxis after kidney transplantation. We aimed to determine the nationwide status of PJP prophylaxis in Korea and compare the incidence, risk factors, and outcomes of early and late PJP using data from the Korean Organ Transplantation Registry (KOTRY), a nationwide Korean transplant cohort. We conducted a retrospective analysis using data of 4,839 kidney transplant patients from KOTRY between 2014 and 2018, excluding patients who received multi-organ transplantation or were under 18 years old. Cox regression analysis was performed to determine risk factors for early and late PJP. A total of 50 patients developed PJP. The number of patients who developed PJP was same between onset before 6 months and onsets after 6 months. There were no differences in the rate, duration, or dose of PJP prophylaxis between early and late PJP. Desensitization, higher tacrolimus dose at discharge, and acute rejection were associated with early PJP. In late PJP, old age as well as acute rejection were significant risk factors. In conclusion late PJP is as common and risky as early PJP and requires individualized risk-based prophylaxis, such as prolonged prophylaxis for old patients with a history of rejection.
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16
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Peng J, Ni M, Du D, Lu Y, Song J, Liu W, Shen N, Wang X, Zhu Y, Vallance BA, Sun Z, Yu HB. Successful treatment of a kidney transplant patient with COVID-19 and late-onset Pneumocystis jirovecii pneumonia. Ann Clin Microbiol Antimicrob 2021; 20:83. [PMID: 34911528 PMCID: PMC8672649 DOI: 10.1186/s12941-021-00489-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 12/09/2021] [Indexed: 12/23/2022] Open
Abstract
Background Solid transplant patients are susceptible to Pneumocystis jirovecii pneumonia (PJP). While the vast majority of PJP cases occur within the first 6 months after transplantation, very few PJP cases are seen beyond 1 year post-transplantation (late-onset PJP). PJP and coronavirus disease 2019 (COVID-19, caused by infection with SARS-CoV-2) share quite a few common clinical manifestations and imaging findings, making the diagnosis of PJP often underappreciated during the current COVID-19 pandemic. To date, only 1 case of kidney transplantation who developed COVID-19 and late-onset PJP has been reported, but this patient also suffered from many other infections and died from respiratory failure and multiple organ dysfunction syndrome. A successful treatment of kidney patients with COVID-19 and late-onset PJP has not been reported. Case presentation We present a case of a 55-year-old male kidney transplant patient with COVID-19 who also developed late-onset PJP. He received a combined treatment strategy, including specific anti-pneumocystis therapy, symptomatic supportive therapy, adjusted immunosuppressive therapy, and use of antiviral drugs/antibiotics, ending with a favorable outcome. Conclusions This case highlights the importance of prompt and differential diagnosis of PJP in kidney transplant patients with SARS-CoV-2 infection. Further studies are required to clarify if kidney transplant patients with COVID-19 could be prone to develop late-onset PJP and how these patients should be treated.
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Affiliation(s)
- Jing Peng
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ming Ni
- Department of Infectious Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dunfeng Du
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanjun Lu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Juan Song
- Department of Gastroenterology & Endocrinology, Wuhan No. 9 Hospital, Wuhan, China
| | - Weiyong Liu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Na Shen
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiong Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yaowu Zhu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bruce A Vallance
- Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, Canada
| | - Ziyong Sun
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Hong Bing Yu
- Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, Canada.
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17
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Mascitti H, Jaffal K. Nouveautés sur la pneumocystose et le CMV chez l’immunodeprimé (hors VIH). Infect Dis Now 2021. [DOI: 10.1016/s2666-9919(21)00557-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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18
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Dashti-Khavidaki S, Saidi R, Lu H. Current status of glucocorticoid usage in solid organ transplantation. World J Transplant 2021; 11:443-465. [PMID: 34868896 PMCID: PMC8603633 DOI: 10.5500/wjt.v11.i11.443] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/16/2021] [Accepted: 11/03/2021] [Indexed: 02/06/2023] Open
Abstract
Glucocorticoids (GCs) have been the mainstay of immunosuppressive therapy in solid organ transplantation (SOT) for decades, due to their potent effects on innate immunity and tissue protective effects. However, some SOT centers are reluctant to administer GCs long-term because of the various related side effects. This review summarizes the advantages and disadvantages of GCs in SOT. PubMed and Scopus databases were searched from 2011 to April 2021 using search syntaxes covering “transplantation” and “glucocorticoids”. GCs are used in transplant recipients, transplant donors, and organ perfusate solution to improve transplant outcomes. In SOT recipients, GCs are administered as induction and maintenance immunosuppressive therapy. GCs are also the cornerstone to treat acute antibody- and T-cell-mediated rejections. Addition of GCs to organ perfusate solution and pretreatment of transplant donors with GCs are recommended by some guidelines and protocols, to reduce ischemia-reperfusion injury peri-transplant. GCs with low bioavailability and high potency for GC receptors, such as budesonide, nanoparticle-mediated targeted delivery of GCs to specific organs, and combination use of dexamethasone with inducers of immune-regulatory cells, are new methods of GC application in SOT patients to reduce side effects or induce immune-tolerance instead of immunosuppression. Various side effects involving different non-targeted organs/tissues, such as bone, cardiovascular, neuromuscular, skin and gastrointestinal tract, have been noted for GCs. There are also potential drug-drug interactions for GCs in SOT patients.
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Affiliation(s)
- Simin Dashti-Khavidaki
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran 14155, Iran
| | - Reza Saidi
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Hong Lu
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
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19
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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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20
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Coussement J, Manuel O. Pneumocystis jirovecii pneumonia and use of mTOR inhibitors in kidney transplantation. Clin Infect Dis 2021; 73:752-753. [PMID: 33449997 DOI: 10.1093/cid/ciab020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Julien Coussement
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Oriol Manuel
- Transplantation Center and Service of Infectious Diseases, Lausanne University Hospital (CHUV), Lausanne, Switzerland
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21
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Cervera C, Yaskina M, Kabbani D. Targeted Prophylaxis to Prevent Late-Onset Pneumocystis jirovecii Pneumonia in Kidney Transplantation: Are We There Yet? Clin Infect Dis 2020; 73:e1464-e1466. [DOI: 10.1093/cid/ciaa1619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- Carlos Cervera
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Li Ka Shing Institute of Virology, University of Alberta, Edmonton, Alberta, Canada
| | - Maryna Yaskina
- Women and Children’s Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Dima Kabbani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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