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Foca M, Demirhan S, Munoz FM, Valencia Deray KG, Bocchini CE, Sharma TS, Sherman G, Muller WJ, Heald-Sargent T, Danziger-Isakov L, Blum S, Boguniewicz J, Bacon S, Joseph T, Smith J, Ardura MI, Su Y, Maron GM, Ferrolino J, Herold BC. Multicenter Analysis of Valganciclovir Prophylaxis in Pediatric Solid Organ Transplant Recipients. Open Forum Infect Dis 2024; 11:ofae353. [PMID: 38979014 PMCID: PMC11229698 DOI: 10.1093/ofid/ofae353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 06/27/2024] [Indexed: 07/10/2024] Open
Abstract
Background Valganciclovir is the only approved antiviral for cytomegalovirus (CMV) prevention in pediatric solid organ transplantation (SOT). Additional approaches may be needed to improve outcomes. Methods A multicenter retrospective study from 2016 to 2019 was conducted of pediatric SOT recipients in whom at least 3 months of valganciclovir prophylaxis was planned. Episodes of CMV DNA in blood (DNAemia), CMV disease, drug-related toxicities, as well as other infections in the first year posttransplant and demographic and clinical data were collected. CMV DNAemia in the first year after prophylaxis or during prophylaxis (breakthrough) was analyzed by multivariate hazard models. Results Among the 749 patients enrolled, 131 (17.5%) had CMV DNAemia at any time in the first year; 85 (11.4%) had breakthrough DNAemia, and 46 (6.1%) had DNAemia after prophylaxis. CMV disease occurred in 30 (4%). In a multivariate model, liver transplantation compared to kidney or heart, intermediate or high risk based on donor/recipient serologies, neutropenia, and valganciclovir dose modifications attributed to toxicity were associated with increased risk of total and/or breakthrough DNAemia. Bacteremia was also associated with increased hazard ratio for CMV DNAemia. In a separate multivariate analysis, rejection occurred more often in those with breakthrough CMV DNAemia (P = .002); liver transplants, specifically, had increased rejection if CMV DNAemia occurred in the first year (P = .004). These associations may be bidirectional as rejection may contribute to infection risk. Conclusions CMV DNAemia in the first year posttransplantation occurs despite valganciclovir prophylaxis and is associated with medication toxicity, bacteremia, and rejection. Pediatric studies of newer antivirals, especially in higher-risk subpopulations, appear to be warranted.
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Affiliation(s)
- Marc Foca
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Salih Demirhan
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Flor M Munoz
- Division of Infectious Diseases, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kristen G Valencia Deray
- Division of Infectious Diseases, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Claire E Bocchini
- Division of Infectious Diseases, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Tanvi S Sharma
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gilad Sherman
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - William J Muller
- Division of Infectious Diseases, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Taylor Heald-Sargent
- Division of Infectious Diseases, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lara Danziger-Isakov
- Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Samantha Blum
- Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Juri Boguniewicz
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Samantha Bacon
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tuhina Joseph
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jodi Smith
- Division of Nephrology, Department of Pediatrics, Seattle Children's Hospital, University of Washington Medical School, Seattle, Washington, USA
| | - Monica I Ardura
- Division of Infectious Diseases and Host Defense, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Yin Su
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Gabriela M Maron
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jose Ferrolino
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Betsy C Herold
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
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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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Hosseini-Moghaddam SM, Kothari S, Humar A, Albasata H, Yetmar ZA, Razonable RR, Neofytos D, D'Asaro M, Boggian K, Hirzel C, Khanna N, Manuel O, Mueller NJ, Imlay H, Kabbani D, Tyagi V, Smibert OC, Nasra M, Fontana L, Obeid KM, Apostolopoulou A, Zhang SX, Permpalung N, Alhatimi H, Silverman MS, Guo H, Rogers BA, MacKenzie E, Pisano J, Gioia F, Rapi L, Prasad GVR, Banegas M, Alonso CD, Doss K, Rakita RM, Fishman JA. Adjunctive glucocorticoid therapy for Pneumocystis jirovecii pneumonia in solid organ transplant recipients: A multicenter cohort, 2015-2020. Am J Transplant 2024; 24:653-668. [PMID: 37977229 DOI: 10.1016/j.ajt.2023.11.003] [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: 06/06/2023] [Revised: 09/21/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
Solid organ transplant recipients (SOTRs) frequently receive adjunctive glucocorticoid therapy (AGT) for Pneumocystis jirovecii pneumonia (PJP). This multicenter cohort of SOTRs with PJP admitted to 20 transplant centers in Canada, the United States, Europe, and Australia, was examined for whether AGT was associated with a lower rate of all-cause intensive care unit (ICU) admission, 90-day death, or a composite outcome (ICU admission or death). Of 172 SOTRs with PJP (median [IQR] age: 60 (51.5-67.0) years; 58 female [33.7%]), the ICU admission and death rates were 43.4%, and 20.8%, respectively. AGT was not associated with a reduced risk of ICU admission (adjusted odds ratio [aOR] [95% CI]: 0.49 [0.21-1.12]), death (aOR [95% CI]: 0.80 [0.30-2.17]), or the composite outcome (aOR [95% CI]: 0.97 [0.71-1.31]) in the propensity score-adjusted analysis. AGT was not significantly associated with at least 1 unit of the respiratory portion of the Sequential Organ Failure Assessment score improvement by day 5 (12/37 [32.4%] vs 39/111 [35.1%]; P = .78). We did not observe significant associations between AGT and ICU admission or death in SOTRs with PJP. Our findings should prompt a reevaluation of routine AGT administration in posttransplant PJP treatment and highlight the need for interventional studies.
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Affiliation(s)
- Seyed M Hosseini-Moghaddam
- Transplant Infectious Diseases and Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sagar Kothari
- Transplant Infectious Diseases and Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Atul Humar
- Transplant Infectious Diseases and Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Hanan Albasata
- Transplant Infectious Diseases and Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Zachary A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Raymund R Razonable
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Dionysios Neofytos
- Transplant Infectious Diseases Unit, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Matilde D'Asaro
- Transplant Infectious Diseases Unit, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Katia Boggian
- Division of Infectious Diseases, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Cedric Hirzel
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland
| | - Oriol Manuel
- Division of Infectious Diseases, University Hospital of Vaud, Lausanne, Switzerland
| | - Nicolas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, Switzerland
| | - Hannah Imlay
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Dima Kabbani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Varalika Tyagi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Olivia C Smibert
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, The University of Melbourne at Austin Health, Heidelberg, Victoria, Australia; Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Mohamed Nasra
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, The University of Melbourne at Austin Health, Heidelberg, Victoria, Australia; Monash Health, Melbourne, Victoria, Australia
| | - Lauren Fontana
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Karam M Obeid
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anna Apostolopoulou
- Transplant Infectious Disease Program and Transplant Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sean X Zhang
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nitipong Permpalung
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hind Alhatimi
- Division of Infectious Diseases, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Michael S Silverman
- Division of Infectious Diseases, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Henry Guo
- Monash Health, Melbourne, Victoria, Australia
| | - Benjamin A Rogers
- Monash Health, Melbourne, Victoria, Australia; School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Erica MacKenzie
- Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Jennifer Pisano
- Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Francesca Gioia
- Department of Infectious Diseases, Hospital Roman y Cajal, Madrid, Spain
| | - Lindita Rapi
- Kidney Transplant Program, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada
| | - G V Ramesh Prasad
- Kidney Transplant Program, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marcela Banegas
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Carolyn D Alonso
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kathleen Doss
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Robert M Rakita
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jay A Fishman
- Transplant Infectious Disease Program and Transplant Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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4
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Saadatzadeh T, Angarone M, Stosor V. Pneumocystis jirovecii in solid organ transplant recipients: updates in epidemiology, diagnosis, treatment, and prevention. Curr Opin Infect Dis 2024; 37:121-128. [PMID: 38230604 DOI: 10.1097/qco.0000000000001002] [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: 01/18/2024]
Abstract
PURPOSE OF REVIEW This review highlights the epidemiology of Pneumocystis jirovecii pneumonia in solid organ transplant recipients, advancements in the diagnostic landscape, and updates in treatment and prevention. RECENT FINDINGS The increasing use of immune-depleting agents in the context of solid organ transplantation has given rise to P. jirovecii pneumonia in this population. The use of prophylaxis has dramatically reduced risk of infection; however, late-onset infections occur after cessation of prophylaxis and in the setting of lymphopenia, advancing patient age, acute allograft rejection, and cytomegalovirus infection. Diagnosis requires respiratory specimens, with PCR detection of Pneumocystis replacing traditional staining methods. Quantitative PCR may be a useful adjunct to differentiate between infection and colonization. Metagenomic next-generation sequencing is gaining attention as a noninvasive diagnostic tool. Trimethoprim-sulfamethoxazole remains the drug of choice for treatment and prevention of Pneumocystis pneumonia. Novel antifungal agents are under investigation. SUMMARY P. jirovecii is a fungal opportunistic pathogen that remains a cause of significant morbidity and mortality in solid organ transplant recipients. Early detection and timely treatment remain the pillars of management.
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Affiliation(s)
| | | | - Valentina Stosor
- Divisions of Infectious Diseases
- Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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5
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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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6
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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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7
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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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8
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Huang L, Xu S, Huang Z, Chen Y, Xu N, Xie B. Risk factors associated with Pneumocystis jirovecii pneumonia in non-HIV immunocompromised patients and co-pathogens analysis by metagenomic next-generation sequencing. BMC Pulm Med 2023; 23:72. [PMID: 36829171 PMCID: PMC9951498 DOI: 10.1186/s12890-022-02300-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/26/2022] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is one of the most common opportunistic infections in immunocompromised patients. However, the accurate prediction of the development of PJP in non-HIV immunocompromised patients is still unclear. METHODS Non-HIV immunocompromised patients confirmed diagnosis of PJP by the clinical symptoms, chest computed tomography and etiological results of metagenomic next-generation sequencing (mNGS) were enrolled as observation group. Another group of matched non-HIV immunocompromised patients with non-PJP pneumonia were enrolled to control group. The risk factors for the development of PJP and the co-pathogens in the bronchoalveolar lavage fluid (BALF) detected by mNGS were analyzed. RESULTS: A total of 67 (33 PJP, 34 non-PJP) participants were enrolled from Fujian Provincial Hospital. The ages, males and underlying illnesses were not significantly different between the two groups. Compared to non-PJP patients, PJP patients were more tends to have the symptoms of fever and dyspnea. The LYM and ALB were significantly lower in PJP patients than in non-PJP patients. Conversely, LDH and serum BDG in PJP patients were significantly higher than in non-PJP controls. For immunological indicators, the levels of immunoglobulin A, G, M and complement C3, C4, the numbers of T, B, and NK cells, had no statistical difference between these two groups. Logistic multivariate analysis showed that concomitant use of corticosteroids and immunosuppressant (OR 14.146, P = 0.004) and the lymphocyte counts < 0.7 × 109/L (OR 6.882, P = 0.011) were risk factors for the development of PJP in non-HIV immunocompromised patients. 81.82% (27/33) and 64.71% (22/34) mixed infections were identified by mNGS in the PJP group and non-PJP group separately. CMV, EBV and Candida were the leading co-pathogens in PJP patients. The percentages of CMV and EBV identified by mNGS in PJP group were significantly higher than those in the control group(p < 0.005). CONCLUSIONS: Clinicians should pay close attention to the development of PJP in non-HIV immunocompromised patients who possess the risk factors of concomitant use of corticosteroids and immunosuppressant and the lymphocyte counts < 0.7 × 109/L. Prophylaxis for PJP cannot rely solely on CD4+ T counts in non-HIV immunocompromised patients. Whether CMV infection increases the risk of PJP remains to be further investigated.
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Affiliation(s)
- Liping Huang
- grid.256112.30000 0004 1797 9307Shengli Clinical Medical college of Fujian Medical University, Fuzhou, 350001 Fujian Province China ,grid.415108.90000 0004 1757 9178Department of Respiratory and Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, 350001 Fujian Province China
| | - Shuyun Xu
- grid.256112.30000 0004 1797 9307Shengli Clinical Medical college of Fujian Medical University, Fuzhou, 350001 Fujian Province China
| | - Zhimin Huang
- grid.256112.30000 0004 1797 9307Shengli Clinical Medical college of Fujian Medical University, Fuzhou, 350001 Fujian Province China
| | - Yusheng Chen
- grid.256112.30000 0004 1797 9307Shengli Clinical Medical college of Fujian Medical University, Fuzhou, 350001 Fujian Province China ,grid.415108.90000 0004 1757 9178Department of Respiratory and Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, 350001 Fujian Province China
| | - Nengluan Xu
- grid.256112.30000 0004 1797 9307Shengli Clinical Medical college of Fujian Medical University, Fuzhou, 350001 Fujian Province China ,grid.415108.90000 0004 1757 9178Department of Respiratory and Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, 350001 Fujian Province China
| | - Baosong Xie
- Shengli Clinical Medical college of Fujian Medical University, Fuzhou, 350001, Fujian Province, China. .,Department of Respiratory and Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, 350001, Fujian Province, China.
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Lee HJ, Kwon HW, Baek JK, Park CH, Seo HK, Hong SK. Risk factors for Pneumocystis pneumonia with acute respiratory failure among kidney transplant recipients. BMC Nephrol 2023; 24:31. [PMID: 36759777 PMCID: PMC9912528 DOI: 10.1186/s12882-023-03071-y] [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: 11/07/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
PURPOSE One of the rare life-threatening fungal infections is pneumocystis pneumonia (PCP). Immunocompromised patients are the main vulnerable population. We investigate the risk factors associated with the development of severe PCP infection with acute respiratory failure after kidney transplantation. MATERIALS AND METHODS This is a retrospective, single-center, case-control study. PCP patients who are kidney transplant recipients and required high-flow oxygen support or mechanical ventilation between March 2009 and February 2017 were included in the study. The comparison was conducted between the non-severe and severe PCP groups. To identify associated risk factors, we performed univariate and multivariate logistic regression. RESULTS Among the total 2,330 kidney transplant recipients, 50 patients (2.1%) were diagnosed with PCP. Of these, 27 patients (54.0%) had severe PCP and 7 patients (14.0%) died, all of them were severe PCP patients. In the severe PCP group, the time from transplantation to PCP diagnosis (23.4 ± 24.9 months vs. 13.7 ± 9.9 months, p = 0.090) was insignificantly faster than in the non-severe PCP group. According to multiple logistic regression analysis, the significant risk factors associated with severe PCP were as follows, age (odds ratios (OR) 1.07; 95% confidence intervals (CI): 1.01-1.13; p = 0.027), time from transplantation to PCP diagnosis (odds ratios (OR) 0.92; 95% confidence intervals (CI): 0.86-0.99; p = 0.024), lymphopenia (OR 6.48; 95% CI: 1.05-40.09; p = 0.044), and history of acute rejection within 1 year (OR 8.28; 95% CI: 1.29-53.20; p = 0.026). CONCLUSION Patients who have lymphopenia at the time of hospital admission or have been recently treated with acute rejection are more likely to progress to severe PCP, requiring intensive monitoring and aggressive treatment.
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Affiliation(s)
- Hak-Jae Lee
- grid.413967.e0000 0001 0842 2126Division of Acute Care Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, 05505 Seoul, Korea
| | - Hyun-Wook Kwon
- grid.413967.e0000 0001 0842 2126Division of Kidney and Pancreas Transplantation, Department of Surgery, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea
| | - Jong-Kwan Baek
- grid.413967.e0000 0001 0842 2126Division of Acute Care Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, 05505 Seoul, Korea
| | - Chan-Hee Park
- grid.413967.e0000 0001 0842 2126Division of Acute Care Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, 05505 Seoul, Korea
| | - Hye-Kyung Seo
- grid.413967.e0000 0001 0842 2126Division of Acute Care Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, 05505 Seoul, Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, 05505, Seoul, Korea.
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Zou J, Qiu T, Zhou J, Wang T, Ma X, Jin Z, Xu Y, Zhang L, Chen Z. Clinical Manifestations and Outcomes of Renal Transplantation Patients With Pneumocystis jirovecii Pneumonia and Cytomegalovirus Co-infection. Front Med (Lausanne) 2022; 9:860644. [PMID: 35479953 PMCID: PMC9035925 DOI: 10.3389/fmed.2022.860644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPneumocystis jirovecii pneumonia (PJP) and cytomegalovirus (CMV) infection are common opportunistic infections among renal transplantation (RT) recipients, and both can increase the risk of graft loss and patient mortality after RT. However, few studies had evaluated PJP and CMV co-infection, especially among RT patients. Therefore, this study was performed to evaluate the impact of CMV co-infection with PJP among RT recipients.MethodsWe retrospectively analyzed the clinical data of patients with confirmed diagnosis of PJP between 2015 and 2021 in our hospital. We divided patients into PJP and PJP+CMV groups according to their CMV infection status, and the clinical severity and outcomes of the two groups were evaluated.ResultsA total of 80 patients after RT were diagnosed with PJP. Of these, 37 (46.2%) patients had co-existing CMV viremia. There were no statistically significant intergroup differences in age, sex, diabetes, onset time of PJP after RT and postoperative immunosuppressant. Compared to serum creatinine (Cr) at admission, the serum Cr at discharge in both the PJP and PJP+CMV groups were decreased. The PJP+CMV group had a higher C-reactive protein level, higher procalcitonin level, and lower albumin level than the PJP group. The PJP+CMV group showed a higher PSI score than the PJP group. Moreover, the initial absorption time of the lesion was longer in the PJP+CMV group. However, the duration of hospitalization showed no significant differences between the two groups. The mortality rate was 9.4-times higher in the PJP+CMV group than in the PJP group. The rate of admittance to the intensive care unit was 3.2-times higher in the PJP+CMV group than in the PJP group.ConclusionCMV co-infection may result in more serious inflammatory response. RT patients with PJP+CMV infection had more severe clinical symptoms, slower recovery from pneumonia, and higher mortality than those with PJP alone. Therefore, when RT patients present with severe PJP, the possibility of CMV co-infection should be considered. Short-term withdrawal of immunosuppressants in case of severe infection is safe for the renal function of RT patients.
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Morovati H, Khodadadi H, Ahmadpour E, Nami S, Mohammadi R, Hosseini H, Behravan M. Global prevalence, mortality, and main risk factors for COVID-19 associated pneumocystosis: A systematic review and meta-analysis. ASIAN PAC J TROP MED 2022. [DOI: 10.4103/1995-7645.359784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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Does Post-Transplant Cytomegalovirus Increase the Risk of Invasive Aspergillosis in Solid Organ Transplant Recipients? A Systematic Review and Meta-Analysis. J Fungi (Basel) 2021; 7:jof7050327. [PMID: 33922773 PMCID: PMC8145336 DOI: 10.3390/jof7050327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 12/20/2022] Open
Abstract
Background: Cytomegalovirus (CMV) and invasive aspergillosis (IA) cause high morbidity and mortality in solid organ transplant (SOT) recipients. There are conflicting data with respect to the impact of CMV on IA development in SOT recipients. Methods: A literature search was conducted from existence through to 2 April 2021 using MEDLINE, Embase, and ISI Web of Science databases. This review contained observational studies including cross-sectional, prospective cohort, retrospective cohort, and case-control studies that reported SOT recipients with post-transplant CMV (exposure) and without post-transplant CMV (non-exposure) who developed or did not develop subsequent IA. A random-effects model was used to calculate the pooled effect estimate. Results: A total of 16 studies were included for systematic review and meta-analysis. There were 5437 SOT patients included in the study, with 449 SOT recipients developing post-transplant IA. Post-transplant CMV significantly increased the risk of subsequent IA with pORs of 3.31 (2.34, 4.69), I2 = 30%. Subgroup analyses showed that CMV increased the risk of IA development regardless of the study period (before and after 2003), types of organ transplantation (intra-thoracic and intra-abdominal transplantation), and timing after transplant (early vs. late IA development). Further analyses by CMV definitions showed CMV disease/syndrome increased the risk of IA development, but asymptomatic CMV viremia/infection did not increase the risk of IA. Conclusions: Post-transplant CMV, particularly CMV disease/syndrome, significantly increased the risks of IA, which highlights the importance of CMV prevention strategies in SOT recipients. Further studies are needed to understand the impact of programmatic fungal surveillance or antifungal prophylaxis to prevent this fungal-after-viral phenomenon.
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13
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No association of genetic variants in TLR4, TNF-α, IL10, IFN-γ, and IL37 in cytomegalovirus-positive renal allograft recipients with active CMV infection-Subanalysis of the prospective randomised VIPP study. PLoS One 2021; 16:e0246118. [PMID: 33861738 PMCID: PMC8051780 DOI: 10.1371/journal.pone.0246118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 01/04/2021] [Indexed: 11/24/2022] Open
Abstract
Background Cytomegalovirus (CMV) infection is amongst the most important factors complicating solid organ transplantation. In a large prospective randomized clinical trial, valganciclovir prophylaxis reduced the occurrence of CMV infection and disease compared with preemptive therapy in CMV-positive renal allograft recipients (VIPP study; NCT00372229). Here, we present a subanalysis of the VIPP study, investigating single nucleotide polymorphisms (SNPs) in immune-response-related genes and their association with active CMV infection, CMV disease, graft loss or death, rejection, infections, and leukopenia. Methods Based on literature research ten SNPs were analyzed for TLR4, three for IFN-γ, six for IL10, nine for IL37, and two for TNF-α. An asymptotic independence test (Cochran-Armitage trend test) was used to examine associations between SNPs and the occurrence of CMV infection or other negative outcomes. Statistical significance was defined as p<0.05 and Bonferroni correction for multiple testing was performed. Results SNPs were analyzed on 116 blood samples. No associations were found between the analyzed SNPs and the occurrence of CMV infection, rejection and leukopenia in all patients. For IL37 rs2723186, an association with CMV disease (p = 0.0499), for IL10 rs1800872, with graft loss or death (p = 0.0207) and for IL10 rs3024496, with infections (p = 0.0258) was observed in all patients, however did not hold true after correction for multiple testing. Conclusion The study did not reveal significant associations between the analyzed SNPs and the occurrence of negative outcomes in CMV-positive renal transplant recipients after correction for multiple testing. The results of this association analysis may be of use in guiding future research efforts.
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14
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Yang P, Zhu X, Liang W, Cai R. The risk factor analysis and treatment experience in pneumocystis jirovecii pneumonia after kidney transplantation. Mycoses 2021; 64:495-502. [PMID: 33368732 DOI: 10.1111/myc.13235] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 11/25/2020] [Accepted: 12/18/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection among solid organ transplantation. The occurrence of PJP is dangerous and fatal if there is no early identification and sufficient treatment. OBJECTIVE The aim of this study was to evaluate the risk factors and provide appropriate strategies of prophylaxis and treatment for PJP after kidney transplantation in our centre. PATIENTS/METHODS From January 2009 to December 2018, a total of 167 kidney transplantation recipients with pneumonia were enrolled, including 47 PJP patients as PJP group and 120 non-PJP patients as control group. The clinical characteristics of the two groups were analysed retrospectively. RESULTS Multivariate analysis showed that high total dosage of ATG [OR, 2.03; 95% CI, 1.12-3.68] and cytomegalovirus (CMV) infection were independent risk factors for PJP. Trimethoprim-sulfamethoxazole (TMP-SMX) (1.44 g q6h)-based treatment was used for 2 weeks, and its dosage and course were adjusted according to the therapeutic effect and side effects. Forty-five cases were recovered after 3 months of follow-up, and two patients died of respiratory failure. TMP-SMX (0.48 g/day) prophylaxis was used for 3-6 months and prolonged to 7-8 months after treatment for acute rejection, which reduced the incidence of PJP compared with those without prophylaxis. CONCLUSION Our study suggests that the high total dosage of ATG and CMV infection indicate the increased risk of PJP. The strategies of prophylaxis and treatment for PJP after kidney transplantation in our centre were effective.
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Affiliation(s)
- Pengfeng Yang
- Department of Ultrasound Medicine, The Third Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Xiaoqiu Zhu
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Weixiang Liang
- Department of Ultrasound Medicine, The Third Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Ruiming Cai
- Department of Renal Transplantation, The Third Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
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15
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A Comprehensive Evaluation of Risk Factors for Pneumocystis Jirovecii Pneumonia in Adult Solid Organ Transplant Recipients: a Systematic Review and Meta-Analysis. Transplantation 2020; 105:2291-2306. [PMID: 33323766 DOI: 10.1097/tp.0000000000003576] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND There is no consensus guidance on when to reinitiate Pneumocystis jirovecii pneumonia (PJP) prophylaxis in solid organ transplant (SOT) recipients at increased risk. The 2019 American Society of Transplantation Infectious Diseases Community of Practice (AST IDCOP) guidelines suggested to continue or reinstitute PJP prophylaxis in those receiving intensified immunosuppression for graft rejection, CMV infection, higher dose of corticosteroids, or prolonged neutropenia. METHODS A literature search was conducted evaluating all literature from existence through April 22, 2020 using MEDLINE and EMBASE. (PROSPERO: CRD42019134204) RESULTS:: A total of 30 studies with 413 276 SOT recipients were included. The following factors were associated with PJP development: acute rejection (pooled odds ratio (pOR) = 2.35 (1.69, 3.26), study heterogeneity index (I)= 23.4%), cytomegalovirus (CMV)-related illnesses (pOR = 3.14 (2.30, 4.29), I=48%), absolute lymphocyte count < 500 cells/mm (pOR = 6.29[3.56, 11.13], I 0%), BK-related diseases (pOR = 2.59[1.22, 5.49], I 0%), HLA mismatch ≥ 3 (pOR = 1.83 [1.06, 3.17], I= 0%), rituximab use (pOR =3.03 (1.82, 5.04); I =0%) and polyclonal antibodies use for rejection (pOR = 3.92 [1.87, 8.19], I= 0%). On the other hand, sex, CMV mismatch, interleukin-2 inhibitors, corticosteroids for rejection, and plasmapheresis were not associated with developing PJP. CONCLUSION PJP prophylaxis should be considered in SOT recipients with lymphopenia, BK-related infections and rituximab exposure in addition to the previously mentioned risk factors in the AST IDCOP guidelines.
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16
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Kaminski H, Belliere J, Burguet L, Del Bello A, Taton B, Poirot-Mazères S, Accoceberry I, Delhaes L, Visentin J, Gregori M, Iriart X, Charpentier E, Couzi L, Kamar N, Merville P. Identification of Predictive Markers and Outcomes of Late-onset Pneumocystis jirovecii Pneumonia in Kidney Transplant Recipients. Clin Infect Dis 2020; 73:e1456-e1463. [DOI: 10.1093/cid/ciaa1611] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 10/19/2020] [Indexed: 12/18/2022] Open
Abstract
Abstract
Background
In the era of prophylaxis, Pneumocystis pneumonia (PCP) has become a late-onset opportunistic infection requiring indications for prolonged prophylaxis to be defined. The primary objective of our study was therefore to evaluate risk factors associated with late-onset PCP. The secondary objective was to assess the impact of this infection on graft and patient survival.
Methods
We conducted a French case-control study in Bordeaux and Toulouse center by matching 1 case to 1–2 controls from the same center based on the transplant date and the type of induction treatment.
Results
Seventy cases and 134 controls were included. PCP occurred at a median of 3 years after transplantation. The total lymphocyte count and CD4+ and CD8+ T-lymphocyte values were lower in the cases than in their matched controls on the day of infection and annually up to 4 years earlier. The covariables independently associated with PCP were the total lymphocyte count 1 year before Pneumocystis, mTOR inhibitors used as maintenance immunosuppressive drugs, and the administration of corticosteroid boluses used in acute rejection. A total lymphocyte count threshold <1000/µL offered the best predictive value for infection occurrence. PCP was associated with high incidence of graft loss and patient death (30% and 17% respectively, 3 years after PCP).
Conclusions
Pneumocystis pneumonia has dramatic consequences in kidney transplant recipients; a targeted prophylaxis based on simple criteria, such as chronic lymphopenia and/or history of corticosteroid boluses, could be useful to avoid life-threatening complications.
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Affiliation(s)
- Hannah Kaminski
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
- Centre National de Recherche Scientifique- Unité Mixte de Recherche 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Julie Belliere
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire Toulouse, Toulouse, France
- Paul Sabatier University, Toulouse, France
| | - Laure Burguet
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
| | - Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire Toulouse, Toulouse, France
| | - Benjamin Taton
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
- Mathematics Modeling for Oncology, Institute of Bordeaux Mathematics, Institut National de Recherche en Informatique et en automatique-Unité Mixte de Recherche 5251, Talence, France
| | - Stéphane Poirot-Mazères
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
| | - Isabelle Accoceberry
- Laboratory of Parasitology-Mycology, Pellegrin University Hospital, Bordeaux, France
| | - Laurence Delhaes
- Laboratory of Parasitology-Mycology, Pellegrin University Hospital, Bordeaux, France
| | - Jonathan Visentin
- Centre National de Recherche Scientifique- Unité Mixte de Recherche 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
- Laboratory of Immunology and Immunogenetics, Pellegrin University Hospital, Bordeaux, France
| | - Marco Gregori
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
| | - Xavier Iriart
- Department of Parasitology-Mycology, Toulouse University Hospital Toulouse, France
- Institut national de la santé et de la recherche médicale U1043, Institut Fédératif de Recherche Bio-Médicale de Toulouse, Toulouse, France
| | - Elena Charpentier
- Department of Parasitology-Mycology, Toulouse University Hospital Toulouse, France
- Institut national de la santé et de la recherche médicale U1043, Institut Fédératif de Recherche Bio-Médicale de Toulouse, Toulouse, France
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
- Centre National de Recherche Scientifique- Unité Mixte de Recherche 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire Toulouse, Toulouse, France
- Paul Sabatier University, Toulouse, France
- Institut national de la santé et de la recherche médicale U1043, Institut Fédératif de Recherche Bio-Médicale de Toulouse, Toulouse, France
| | - Pierre Merville
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
- Centre National de Recherche Scientifique- Unité Mixte de Recherche 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
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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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18
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Lee S, Park Y, Kim SG, Ko EJ, Chung BH, Yang CW. The impact of cytomegalovirus infection on clinical severity and outcomes in kidney transplant recipients with Pneumocystis jirovecii pneumonia. Microbiol Immunol 2020; 64:356-365. [PMID: 31994768 DOI: 10.1111/1348-0421.12778] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/21/2020] [Accepted: 01/25/2020] [Indexed: 02/06/2023]
Abstract
Cytomegalovirus (CMV) infection is associated with Pneumocystis jirovecii pneumonia (PJP) in kidney transplant recipients (KTRs), but its impact on clinical severity and outcomes in KTRs with PJP is unknown. We reviewed 1994 medical records of KTRs from January 1997 to March 2019. PJP or CMV infection was diagnosed by polymerase chain reaction or culturing using blood or respiratory specimens. We divided patients into PJP and PJP+CMV groups, and evaluated the clinical severity and outcomes. Fifty two patients had PJP (2.6%) in the whole study cohort. Among patients with PJP, 38 (73.1%) had PJP alone and 14 (26.9%) had combined PJP and CMV co-infection. The PJP+CMV group showed worse laboratory findings (serum albumin and C-reactive protein, P = 0.010 for both) and higher requirement of continuous renal replacement therapy than the PJP group (P = 0.050). The pneumonia severity was worse in the PJP+CMV group than in the PJP group (P < 0.05), and CMV infection was a high risk factor of pneumonia severity (odds ratio 16.0; P = 0.002). The graft function was worse in the PJP+CMV group (P < 0.001), and the incidence of graft failure was higher in the PJP+CMV group than in the PJP group (85.7% vs 36.8%; P < 0.001). Mortality was double in the PJP+CMV group than in the PJP group, but not statistically significant (21.4% vs 10.5%; P = 0.370). Our results show that approximately one in four patients with PJP after kidney transplantation develops CMV with increased clinical severity and risk of graft failure. The possibility of increased clinical severity and worse clinical outcomes by CMV co-infection should be considered in KTRs with PJP.
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Affiliation(s)
- Sua Lee
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Yohan Park
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Seong Gyu Kim
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Eun Jeong Ko
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Convergent Research Consortium for Immunologic Disease, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Byung Ha Chung
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Convergent Research Consortium for Immunologic Disease, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Chul Woo Yang
- Department of Internal Medicine, College of Medicine, Transplant Research Center, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Convergent Research Consortium for Immunologic Disease, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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19
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Park SY, Jung JH, Kwon H, Shin S, Kim YH, Chong YP, Lee SO, Choi SH, Kim YS, Woo JH, Kim SH, Han DJ. Epidemiology and risk factors associated with Pneumocystis jirovecii pneumonia in kidney transplant recipients after 6-month trimethoprim-sulfamethoxazole prophylaxis: A case-control study. Transpl Infect Dis 2020; 22:e13245. [PMID: 31943590 DOI: 10.1111/tid.13245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 11/15/2019] [Accepted: 01/05/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pneumocystis jirovecii pneumonia (PCP) is an important cause of morbidity and mortality in kidney transplant recipients (KTRs), and prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) is recommended. The aim of this study was to investigate incidence and risk factors for PCP in KTRs after 6-month TMP-SMX prophylaxis. METHODS We conducted a case-control study of patients with PCP who received 6-month PCP prophylaxis with TMP-SMX after kidney transplantation (KT). In cases of rejection, PCP prophylaxis was provided for six additional months after anti-rejection therapy. Cytomegalovirus (CMV) infection was not considered an indication for PCP prophylaxis due to concerns of nephrotoxicity associated with TMP-SMX. RESULTS Among 3941 kidney or pancreas-kidney transplant recipients, 67 (1.7%) developed PCP after discontinuing TMP-SMX. A total of 47 patients with KT PCP and 94 controls were included. Duration of PCP prophylaxis was similar between cases and controls (median 6 months, P = .53). In multivariate analysis, rejection (OR 3.9; 95% CI 1.4-11.1) and CMV infection (OR 2.4; 95% CI 1.0-5.8) were independently associated with PCP development after TMP-SMX. Rejection or CMV infection was observed in 70% of patients with PCP. Time to PCP development after rejection (median [IQR] 6 [5-19] months) was slightly shorter than after CMV infection (median [IQR] 9 [5-12] months; P = .18). CONCLUSION Post-prophylaxis PCP occurred in <2% of KTRs, and about two-thirds of these experienced rejection or CMV infection. These data suggest that at least 6 to 9-month additional chemoprophylaxis may be needed to prevent PCP in KTRs with transplant rejection or CMV infection.
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Affiliation(s)
- Se Yoon Park
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Joo Hee Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyunwook Kwon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Shin
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hoon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Phil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duck Jong Han
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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20
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Abstract
PURPOSE OF REVIEW Invasive fungal disease (IFD) and cytomegalovirus (CMV) infections occur frequently, either concomitantly or sequentially in immune-compromised hosts. Although there is extensive knowledge of the risk factors for these infections as single entities, the inter-relationship between opportunistic fungii and CMV has not been comprehensively explored. RECENT FINDINGS Both solid organ and stem cell transplant recipients who develop CMV invasive organ disease are at an increased risk of developing IFD, particularly aspergillosis and Pneumocystis pneumonia (PCP). Moreover, CMV viremia and recipient CMV serostatus also increased the risk of both early and late-onset IFD. Treatment-related factors, such as ganciclovir-induced neutropenia and host genetic Toll-like receptor (TLR) polymorphisms are likely to be contributory. Less is known about the relationship between CMV and IFD outside transplantation, such as in patients with hematological cancers or other chronic immunosuppressive conditions. Finally, few studies report on the relationship between CMV-specific treatments or the viral/antigen kinetics and its influence on IFD management. SUMMARY CMV infection is associated with increased risk of IFD in posttransplant recipients because of a number of overlapping and virus-specific risk factors. Better understanding of how CMV virus, its related treatment, CMV-induced immunosuppression and host genetic factors impact on IFD is warranted.
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21
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Jorgenson MR, Descourouez JL, Lyu B, Astor BC, Garg N, Smith JA, Mandelbrot DA. The risk of cytomegalovirus infection after treatment of acute rejection in renal transplant recipients. Clin Transplant 2019; 33:e13636. [PMID: 31194887 DOI: 10.1111/ctr.13636] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 06/02/2019] [Accepted: 06/07/2019] [Indexed: 12/20/2022]
Abstract
The risk of cytomegalovirus infection (CMV) after rejection treatment is poorly understood. To investigate this, we conducted a case/control (1:2) analysis of adult renal transplant recipients between January 1, 2005 and December 31, 2015, via incidence density sampling and survival analysis. Our objective was to evaluate the association of prior acute rejection with subsequent CMV, including epidemiology and outcomes. There were 2481 eligible renal transplants within the study period and 251 distinct CMV infections. Despite the use of antiviral prophylaxis rejection was a significant risk factor for CMV on unadjusted (HR 1.73 [1.34, 2.24] P < 0.05) and adjusted analysis (HR 1.46 [1.06, 2.04] P < 0.05). When matching cases to controls patients with CMV had significantly more rejection prior to CMV diagnosis (26.7% vs 14.2%, P < 0.01). CMV was associated with a twofold increased risk of prior rejection on unadjusted (OR 1.94, 95%CI: 1.28-2.96, P < 0.01) and adjusted analysis (OR 2.16, 95% CI: 1.31-3.58, P < 0.01). Patients with rejection preceding CMV had significantly increased graft loss (HR 2.89, 95% CI: 1.65-5.09, P < 0.01) and mortality (HR 1.82, 95% CI: 1.12-4.24, P = 0.03) as compared to those CMV cases without rejection. In conclusion, rejection is a risk factor for CMV infection that appears to persist for 1 year. Preceding rejection events increased risk of graft loss and mortality in CMV patients. Given this, prolonged surveillance monitoring for CMV after rejection may be warranted. Studies are needed investigating optimal monitoring strategies.
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Affiliation(s)
- Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Jillian L Descourouez
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Beini Lyu
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Brad C Astor
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Neetika Garg
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jeannina A Smith
- Department of Medicine, Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Didier A Mandelbrot
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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22
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Cereser L, Dallorto A, Candoni A, Volpetti S, Righi E, Zuiani C, Girometti R. Pneumocystis jirovecii pneumonia at chest High-resolution Computed Tomography (HRCT) in non-HIV immunocompromised patients: Spectrum of findings and mimickers. Eur J Radiol 2019; 116:116-127. [PMID: 31153552 DOI: 10.1016/j.ejrad.2019.04.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/21/2019] [Accepted: 04/30/2019] [Indexed: 01/08/2023]
Abstract
Pneumocystis jirovecii pneumonia (PJP) has emerged as a main issue in non Human Immunodeficiency Virus (HIV) immunocompromised hosts, exposing patients to high mortality rates, especially when the diagnosis is delayed. Since microbiological confirmation is often unfeasible or difficult to obtain, High-resolution Computed Tomography (HRCT) represents a main tool for guiding the diagnosis in the appropriate clinical scenario. Nevertheless, radiologists must be aware that PJP at HRCT is a multifaceted process, with a variety of common and less frequent findings, along with a broad spectrum of infectious (e.g., viral and certain fungal and bacterial pneumonias) and non-infectious (e.g., pulmonary oedema, diffuse alveolar haemorrhage, and drug toxicity) differential diagnoses. In this review we resume background clinical information on PJP in non-HIV immunocompromised patients, illustrate both typical and less frequent HRCT findings, and present the spectrum of infectious and non-infectious mimickers at HRCT, highlighting the similarities with PJP and providing clues for the differential diagnosis.
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Affiliation(s)
- Lorenzo Cereser
- Institute of Radiology, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria Integrata di Udine, p.le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Anna Dallorto
- Institute of Radiology, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria Integrata di Udine, p.le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Anna Candoni
- Division of Haematology and Stem Cell Transplantation, University Hospital of Udine, Azienda Sanitaria Universitaria Integrata di Udine, p.le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Stefano Volpetti
- Division of Haematology and Stem Cell Transplantation, University Hospital of Udine, Azienda Sanitaria Universitaria Integrata di Udine, p.le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Elda Righi
- Infectious Diseases, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Integrata di Udine, p.le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Chiara Zuiani
- Institute of Radiology, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria Integrata di Udine, p.le S. Maria della Misericordia 15, 33100, Udine, Italy.
| | - Rossano Girometti
- Institute of Radiology, Department of Medicine, University of Udine, Azienda Sanitaria Universitaria Integrata di Udine, p.le S. Maria della Misericordia 15, 33100, Udine, Italy.
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23
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Jorgenson MR, Descourouez JL, Cardinale B, Lyu B, Astor BC, Garg N, Saddler CM, Smith JA, Mandelbrot DA. Risk of opportunistic infection in kidney transplant recipients with cytomegalovirus infection and associated outcomes. Transpl Infect Dis 2019; 21:e13080. [DOI: 10.1111/tid.13080] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/30/2019] [Accepted: 03/12/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Margaret R. Jorgenson
- Department of Pharmacy University of Wisconsin Hospital and Clinics Madison Wisconsin
| | | | | | - Beini Lyu
- Department of Medicine and Population Health Sciences University of Wisconsin‐Madison School of Medicine and Public Health Madison Wisconsin
| | - Brad C. Astor
- Department of Medicine and Population Health Sciences University of Wisconsin‐Madison School of Medicine and Public Health Madison Wisconsin
| | - Neetika Garg
- Department of Medicine University of Wisconsin‐Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics Madison Wisconsin
| | - Christopher M. Saddler
- Department of Medicine University of Wisconsin‐Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics Madison Wisconsin
| | - Jeannina A. Smith
- Department of Medicine University of Wisconsin‐Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics Madison Wisconsin
| | - Didier A. Mandelbrot
- Department of Medicine University of Wisconsin‐Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics Madison Wisconsin
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24
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Garg N, Jorgenson M, Descourouez J, Saddler CM, Parajuli S, Astor BC, Djamali A, Mandelbrot D. Pneumocystis jiroveci pneumonia in kidney and simultaneous pancreas kidney transplant recipients in the present era of routine post-transplant prophylaxis: risk factors and outcomes. BMC Nephrol 2018; 19:332. [PMID: 30463516 PMCID: PMC6249739 DOI: 10.1186/s12882-018-1142-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/15/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The goal of this study was to identify predictors for development of Pneumocystis jirovecii pneumonia (PJP) in kidney and simultaneous kidney and pancreas transplant recipients in the present era of universal primary prophylaxis. METHODS We reviewed adult recipients of kidney transplant or simultaneous pancreas and kidney transplant at the University of Wisconsin between January 1, 1994 and December 31, 2016. Patients diagnosed with PJP during this time frame were included. Controls were randomly selected from among those whose post-transplant course was not complicated by PJP, matched on time since transplant through incidence density sampling with a 3:1 ratio. RESULTS 28 (0.45%) of 6270 recipients developed PJP between 1994 and 2016. Median time since transplant was 4.6 years (interquartile range (IQR): 1.4-9.6 years). Affected recipients were older, had more HLA mismatches, and were more likely to have had BK viremia, CMV viremia and invasive fungal infections than matched controls. CMV viremia remained the only significant risk factor in multivariate analysis, and was a strong predictor (OR 6.27; p = 0.002). Ninety percent of the cases with prior CMV viremia had been diagnosed in the year preceding the diagnosis of PJP; among these, median time from diagnosis of CMV to diagnosis of PJP was 3.4 months (IQR: 1.74-11.5 months) and median peak CMV viral load prior to diagnosis of PJP was 3684.5 IU/mL (IQR: 1034-93,300 IU/mL). Additionally, 88.9% of patients with CMV in the preceding year had active infection at time of PJP diagnosis. Patient and graft survival were significantly worse at 2 years in recipients with PJP than our control group (42.4% vs. 88.5, and 37.9% vs. 79.9%; p < 0.001). CONCLUSIONS Despite the low overall incidence of PJP in the era of universal prophylaxis, outcomes are poor. We suggest extending or re-initiating PJP prophylaxis for at least 6 months in the setting of CMV viremia due to the relatively low risk of therapy and potential significant impact on disease prevention.
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Affiliation(s)
- Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, 4177 Medical Foundation Centennial Building, Madison, WI, 53705, USA
| | - Margaret Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Jillian Descourouez
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Christopher M Saddler
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, 4177 Medical Foundation Centennial Building, Madison, WI, 53705, USA
| | - Brad C Astor
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, 4177 Medical Foundation Centennial Building, Madison, WI, 53705, USA.,Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, 4177 Medical Foundation Centennial Building, Madison, WI, 53705, USA.,Division of Transplant Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, 4177 Medical Foundation Centennial Building, Madison, WI, 53705, USA.
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