Hospitalizations for fungal infections after initiation of chronic dialysis in the United States

The influence of continuous renal replacement therapy on 1,3-β-d-glucan levels in critically ill patients: a single-center retrospective propensity score study

1,3-β-d-Glucan (BDG) is commonly used for diagnosing invasive fungal infections (IFIs). While exposure to cellulose-based hemodialyzers is known to cause false-positive BDG results, the impact of modern hemofilters used in continuous renal replacement therapy (CRRT) remains unclear. This retrospective, single-center cohort study aimed to evaluate the effect of CRRT on BDG levels in critically ill patients. We included adult intensive care unit (ICU) patients with ≥1 BDG measurement between December 2019 and December 2020. The primary outcome was the rate of false-positive BDG results in patients exposed to CRRT compared to unexposed patients. Propensity score analysis was performed to control for confounding factors. A total of 103 ICU patients with ≥1 BDG level were identified. Most (72.8%) were medical ICU patients. Forty patients underwent CRRT using hemofilter membranes composed of sodium methallyl sulfonate copolymer (AN 69 HF) (82.5%) and of polyarylethersulfone (PAES) (17.5%). Among the 91 patients without proven IFI, 31 (34.1%) had false-positive BDG results. Univariable analysis showed an association between CRRT exposure and false-positive BDG results. However, the association between CRRT exposure and false-positive BDG results was no longer significant across three propensity score models employed: 1:1 match (n = 32) (odds ratio (OR) 1.65, p = .48), model-adjusted (n = 91) (OR 1.75, p = .38), quintile-adjusted (n = 91) (OR 1.78, p = .36). In this single-center retrospective analysis, exposure to synthetic CRRT membranes did not independently increase the risk of false-positive BDG results. Larger prospective studies are needed to further evaluate the association between CRRT exposure and false-positive BDG results in critically ill patients with suspected IFI.

Aortic valve neocuspidization using bovine pericardium for prosthetic valve endocarditis in a hemodialysis patient

BACKGROUND

Hemodialysis patients are at high risk for prosthetic valve endocarditis (PVE) because of the risk of bacteria entering with each hemodialysis session. To avoid the use of artificial materials as much as possible, we performed aortic valve neocuspidization (AVNeo) using bovine pericardium.

CASE PRESENTATION

A 67-year-old patient had undergone aortic valve replacement using a bioprosthetic valve 4 months previous. For the past month, he had had PVE caused by Candida glabrata. Because the pericardium had already been incised in the previous surgery and there was not enough pericardium left for neocuspidization, we performed AVNeo using bovine pericardium. The previously implanted bioprosthetic valve revealed sticky fungal warts on the leaflet and valve ring, which prevented the movement of the valves. We cut all of the threads holding the valve and removed the bioprosthetic valve. Three valves were cut from the bovine pericardium using a unique template following the method of Ozaki et al. and were fixed to the valve ring with a running suture. The postoperative course was good.

CONCLUSIONS

We believe that this treatment is an effective method for PVE because we can avoid the use of artificial materials as much as possible.

Predictors and outcomes of peritoneal dialysis-related infections due to filamentous molds (MycoPDICS)

Introduction

We sought to evaluate the predictors and outcomes of mold peritonitis in patients with peritoneal dialysis (PD).

Methods

This cohort study included PD patients from the MycoPDICS database who had fungal peritonitis between July 2015-June 2020. Patient outcomes were analyzed by Kaplan Meier curves and the Log-rank test. Multivariable Cox proportional hazards model regression was used to estimating associations between fungal types and patients’ outcomes.

Results

The study included 304 fungal peritonitis episodes (yeasts n = 129, hyaline molds n = 122, non-hyaline molds n = 44, and mixed fungi n = 9) in 303 patients. Fungal infections were common during the wet season (p <0.001). Mold peritonitis was significantly more frequent in patients with higher hemoglobin levels, presentations with catheter problems, and positive galactomannan (a fungal cell wall component) tests. Patient survival rates were lowest for non-hyaline mold peritonitis. A higher hazard of death was significantly associated with leaving the catheter in-situ (adjusted hazard ratio [HR] = 6.15, 95%confidence interval [CI]: 2.86–13.23) or delaying catheter removal after the diagnosis of fungal peritonitis (HR = 1.56, 95%CI: 1.00–2.44), as well as not receiving antifungal treatment (HR = 2.23, 95%CI: 1.25–4.01) or receiving it for less than 2 weeks (HR = 2.13, 95%CI: 1.33–3.43). Each additional day of antifungal therapy beyond the minimum 14-day duration was associated with a 2% lower risk of death (HR = 0.98, 95%CI: 0.95–0.999).

Conclusion

Non-hyaline-mold peritonitis had worse survival. Longer duration and higher daily dosage of antifungal treatment were associated with better survival. Deviations from the 2016 ISPD Peritonitis Guideline recommendations concerning treatment duration and catheter removal timing were independently associated with higher mortality.

Membranous nephropathy with pulmonary cryptococcosis with improved 1-year follow-up results: A case report

Cryptococcosis is frequently found in immunosuppressed patients. It is also a significant opportunistic infection in non-immunocompromised individuals. In this study, we present a rare case of membranous nephropathy (MN) with pulmonary cryptococcosis. A 33-year-old man with MN was referred to our hospital because of dyspnea and weakness for 1 week. Before the above symptoms occurred, the dose of Cyclosporin A was increased again for relapse of MN. Multiple massive or patchy high-density shadows were present on computed tomography of the lung. Initially the patient underwent empirical anti-bacterial therapy, which turned out to be ineffective. As the results of serum cryptococcal latex agglutination tests were positive, the administration of anti-fungal drugs was prescribed. The results of fungal culture and pathologic examination of the lung tissue revealed the findings consistent with Cryptococcus neoformans. The patient was successfully treated with voriconazole followed by fluconazole with satisfactory result. Therefore, in patients with chronic kidney disease, lung lesions with poor bactericidal effects of cephalosporins need further examination to make sure whether there is pulmonary cryptococcosis. Early diagnosis and treatment might contribute to good results. It is a problem worthy of consideration that whether immunosuppressive agents need to be discontinued or not during antifungal therapy.

Talaromyces (Penicillium) Species Infection in the Central Nervous System

Talaromycosis typically occurs as an opportunistic infection among immunocompromised individuals. Infection caused by species other than T. marneffei is uncommon. While most reported cases describe infection in the lungs, we report an extremely rare intracranial Talaromyces species infection. This 61-year-old with end-stage renal disease who was unwell for the previous two months, presented with fever and worsening confusion lasting for three days. Lumbar puncture was suggestive of meningitis. Cerebrospinal fluid (CSF) culture was later confirmed to be Penicillium chrysogenum. The patient was co-infected with Group B Streptococcus sepsis. He improved with amphotericin B and ceftriaxone and was discharged with oral itraconazole for four weeks. However, he died of unknown causes two weeks later at home. Talaromyces species infection in the central nervous system is uncommon. This case highlighted a rare but life-threatening fungal meningitis. Among the four reported cases worldwide, none of the patients survived.

Cryptococcosis masquerading as disseminated tuberculosis in a patient on chronic hemodialysis

Chronic hemodialysis (HD) recipients are nearly ten times more prone to fungal infections compared to the general population. However, infections such as cryptococcosis usually affect immunocompromised patients, unusual in otherwise immunocompetent patients. Here, we describe a unique case of cryptococcosis in a human immunodeficiency virus negative end-stage renal disease (ESRD) patient. A 26-year-old female patient, diagnosed with ESRD, on maintenance HD for the past six months, presented with pyrexia of unknown origin associated with cervical lymphadenopathy, biopsy of which showed granulomatous inflammation. The patient was initiated on anti-tubercular treatment but did not respond to treatment. A month later, she developed skin lesions; biopsy and culture from scrapings of the lesions were suggestive of infection with Cryptococcus neoformans. She responded to antifungal therapy very well, with a resolution of fever and skin lesions within a month. This is a unique case report, in which cryptococcosis mimicked tuberculosis in an otherwise immunocompetent patient with ESRD.

Histoplasma Peritonitis: An Extremely Rare Complication of Peritoneal Dialysis

Bacterial peritonitis is a common complication of peritoneal dialysis, but fungal peritonitis is unusual and is mostly due to Candida species. Peritonitis due to Histoplasma capsulatum is rare and we report one such case. A 63-year-old female presented with progressively worsening abdominal pain, fever, and altered mental status. She had end-stage renal disease and had been on peritoneal dialysis for 4 years. She had abdominal tenderness without rebound or guarding. Laboratory studies and CT of abdomen were significant for leukocytosis and peritoneal membrane thickening, respectively. Peritoneal dialysis fluid study was consistent with peritonitis and culture of the fluid grew Histoplasma capsulatum. Treatment recommendations include removal of catheter and initiation of antifungal therapy. With the availability of newer antifungals, medical management without removal of PD catheter is possible, but at the same time if there is no response to treatment within a week, PD catheter should be removed promptly.

Cryptococcosis in HIV-negative Patients with Renal Dialysis: A Retrospective Analysis of Pooled Cases

Cryptococcosis is a lethal fungal infection mainly caused by Cryptococcus neoformans/C. gattii species. Currently, our understanding of cryptococcosis episodes in HIV-negative patients during renal dialysis remains scarce and fragmented. Here, we performed an analysis of pooled cases to systemically summarize the epidemiology and clinical characteristics of cryptococcosis among HIV-negative patients with renal dialysis. Using pooled data from our hospital and studies identified in four medical databases, 18 cases were identified and analyzed. The median duration time of renal dialysis for peritoneal renal dialysis and hemodialysis cases was 8 months and 36 months, respectively. Several non-neoformans/gattii species were identified among the renal dialysis recipients with cryptococcosis, particularly Cryptococcus laurentii and Cryptococcus albidus, which share similar clinical manifestations as those caused by C. neoformans and C. gattii. Our analyses suggest that physicians should consider the possibility of the occurrence of cryptococcosis among renal dialysis recipients even when cryptococcal antigen test result is negative. The timely removal of the catheter is crucial for peritoneal dialysis patients with cryptococcosis. In addition, there is a need for optimized antifungal treatment strategy in renal dialysis recipients with cryptococcal infections.

Oral yeast colonization in peritoneal dialysis and hemodialysis patients and renal transplant recipients

OBJECTIVE

We aimed to investigate the frequency of oral yeast colonization (OYC) and the risk factors for patients who received continuous ambulatory peritoneal dialysis (CAPD) or hemodialysis (HD) or were renal transplant recipients (RTRs). The patients admitted to the Nephrology Clinic at Ataturk University Medical School from January through April 2013 were included in the study. A questionnaire about risk factors was filled out, and swab cultures were taken from the tongue surface of each participant. OYC was detected in 32.1% of the RTRs, 40% of the HD patients, 20.9% of the CAPD patients, and 18% of the healthy control (HC) group. Of the 42 yeast strains isolated from the renal replacement therapy groups, 26 strains (61.9%) were Candida albicans, nine (21.4%) were Candida glabrata, two (4.7%) were Candida krusei, two (4.7%) were Candida kefyr, one (2.38%) was Candida parapsilosis, and two (4.7%) were Geotrichum candidum. Risk factors for OYC in the RTRs group included antibiotic use and the presence of dental prostheses; however, in patients with chronic renal failure undergoing CAPD, only the presence of dental prostheses was found to be a statistically significant risk factor. Although OYC was mostly detected in patients with chronic kidney disease (undergoing HD, a variety of isolated yeast strains in the RTRs was noted. The rates of OYC and isolated Candida species in CAPD were similar to those of the HC group.

Incidence of infection according to intravenous immunoglobulin use in autologous hematopoietic stem cell transplant recipients with multiple myeloma

BACKGROUND

Although intravenous immunoglobulin (IVIG) is not routinely recommended, many centers still use IVIG during the post-hematopoietic stem cell transplant (HSCT) period.

METHOD

A total of 162 multiple myeloma (MM) patients who underwent autologous (auto-) HSCT between January 2008 and June 2013 were retrospectively reviewed. Primary objective was determination of the impact of IVIG on post-transplant infection, and secondary objectives included identification of overall incidence of infection, type of infection, and risk factors for infection after auto-HSCT in MM patients.

RESULTS

After auto-HSCT, 53 of 162 patients (32.7%) experienced 104 infectious events. Upper respiratory infection was most common (n = 31, 29.8%) and pneumonia (n = 27, 26.0%) and herpes zoster (n = 15, 14.4%) came next. Among the identifiable organisms causing respiratory infection, influenza virus (n = 10) and Pneumococcus (n = 9) were predominant. Incidence of infection was not statistically different according to IVIG use (34.8% in IVIG (-) vs. 31.3% in IVIG (+), P = 0.631). Incidence of infection requiring hospitalization and multiple episodes of infection showed no difference between the groups (P = 0.147, P = 0.156). In a Cox proportional hazard model, none of the factors including age, gender, type of disease, stage, tandem (vs. single) transplantation,and IVIG was prognostic for infectious event after auto-HSCT (P = 0.955, hazard ratio 0.980 with 95% confidence interval 0.481-1.997 for IVIG).

CONCLUSION

In auto-HSCT recipients with MM, incidence of post-transplant infection was not different according to prophylactic IVIG use.

Reliability of serum 1,3-beta-D-glucan assay in patients undergoing renal replacement therapy: a review of the literature

The serum 1,3-beta-D-glucan (BDG) test is a pan-fungal serum marker considered to detect the majority of pathogenic fungi, including Aspergillus spp. and Candida spp. For this review we searched for publications dealing with serum BDG levels in patients undergoing renal replacement therapy (RRT). The influence of various different membrane materials used for RRTs in these publications on serum BDG has been reviewed. We found that unmodified cellulose containing membranes increased the serum BDG levels highly, whereas conflicting results have been observed for modified cellulose containing materials. Synthetic materials (e.g. polysuflone) had no influence on serum BDG levels in the majority of the reviewed publications.

Comparative effectiveness studies to improve clinical outcomes in end stage renal disease: the DEcIDE patient outcomes in end stage renal disease study

BACKGROUND

Evidence is lacking to inform providers' and patients' decisions about many common treatment strategies for patients with end stage renal disease (ESRD).

METHODS/DESIGN

The DEcIDE Patient Outcomes in ESRD Study is funded by the United States (US) Agency for Health Care Research and Quality to study the comparative effectiveness of: 1) antihypertensive therapies, 2) early versus later initiation of dialysis, and 3) intravenous iron therapies on clinical outcomes in patients with ESRD. Ongoing studies utilize four existing, nationally representative cohorts of patients with ESRD, including (1) the Choices for Healthy Outcomes in Caring for ESRD study (1041 incident dialysis patients recruited from October 1995 to June 1999 with complete outcome ascertainment through 2009), (2) the Dialysis Clinic Inc (45,124 incident dialysis patients initiating and receiving their care from 2003-2010 with complete outcome ascertainment through 2010), (3) the United States Renal Data System (333,308 incident dialysis patients from 2006-2009 with complete outcome ascertainment through 2010), and (4) the Cleveland Clinic Foundation Chronic Kidney Disease Registry (53,399 patients with chronic kidney disease with outcome ascertainment from 2005 through 2009). We ascertain patient reported outcomes (i.e., health-related quality of life), morbidity, and mortality using clinical and administrative data, and data obtained from national death indices. We use advanced statistical methods (e.g., propensity scoring and marginal structural modeling) to account for potential biases of our study designs. All data are de-identified for analyses. The conduct of studies and dissemination of findings are guided by input from Stakeholders in the ESRD community.

DISCUSSION

The DEcIDE Patient Outcomes in ESRD Study will provide needed evidence regarding the effectiveness of common treatments employed for dialysis patients. Carefully planned dissemination strategies to the ESRD community will enhance studies' impact on clinical care and patients' outcomes.

Aberrant function and differentiation of monocytes in end stage renal disease

Patients with end stage renal disease (ESRD) suffer from many disturbances of the immune system. These immunopathologies are related to the higher failure of vaccination, and increased prevalence of infections and neoplasms. In the presented article, we review the current data regarding the role of monocytes in immune dysfunctions which are observed in terminal renal failure. As monocytes play a pivotal role in regulating the function of the immune system, their dysfunction can have a profound effect on the immune system and may lead to accelerated arteriosclerosis and deteriorating overall health conditions. More specifically, we suggest that peripheral blood monocytes in patients with ESRD are chronically activated, and their functional and phenotypical features resemble those of inflammatory macrophages. This state of chronic inflammation is unfavorable for dendritic cells and consequently, the prevalence of dendritic cells is reduced. As these effects are consistent across different modes of dialysis, they are probably mediated by the uremia itself.

Diabetes and kidney transplantation: past, present, and future

Diabetes mellitus is the most common etiology for end stage renal disease (ESRD) worldwide and in the United States. The incidence of morbidity and mortality is higher in diabetic patients with ESRD due to increased cardiovascular events. Patients with type 2 diabetes who receive a renal allograft have a higher survival rate compared with patients who are maintained on chronic hemodialysis therapy, but there is scarcity of data on long-term graft outcomes. Most recently the development of new onset diabetes after transplantation (NODAT) poses a serious threat to patient and allograft survival. Pre-emptive transplantation and the use of living donors have improved overall survival. In addition, critical management of glucose, blood pressure, and cholesterol are some of the factors that can help minimize adverse outcomes in both patients with pre-existing diabetes and patients who develop NODAT. Future clinical trials are warranted to improve therapeutic medical management of these patients thus influencing graft attrition.

Paradoxical cryptococcal immune reconstitution inflammatory syndrome in advanced chronic kidney disease

Cryptococcal-related immune reconstitution inflammatory syndrome (IRIS) is frequently seen in immunocompromised patients. A 45-year-old man with advanced chronic kidney disease (CKD) received intensive antifungal treatment for pulmonary cryptococcosis. Despite negative pleural effusion cultures and declining serum cryptococcal antigen titers, the patient presented with progressive pulmonary infiltration, intermittent fever, and elevated C-reactive protein. Steroids were given for suspected IRIS, and the clinical condition improved dramatically. This is the first report on paradoxical cryptococcal IRIS in a patient with advanced CKD.

Hypercalcemia and Elevated Serum 1.25‐Dihydroxyvitamin D in an End‐stage Renal Disease Patient with Pulmonary Cryptococcosis

Hypercalcemia occurs relatively often in dialysis patients. The most common cause of hypercalcemia in dialysis patients is the conventional therapy with calcium and calcitriol. Besides, secondary hyperparathyroidism, low turnover bone diseases, and immobilization are also common causes of hypercalcemia in dialysis patients. Fungal infection associated with hypercalcemia has been infrequently reported. We describe a 71-year-old female woman with end-stage renal disease and diabetes mellitus, who developed severe hypercalcemia. Pulmonary cryptococcosis, with increased concentration of serum 1,25-dihydroxyvitamin D (1,25(OH)2D), was diagnosed. Her serum concentration of calcium and 1,25(OH)2D returned to normal after antifungal treatment. Thus, hypercalcemia was mediated by extrarenal overproduction of 1,25(OH)2D in this patient.

Pap smear findings in chronic renal failure patients compared with the normal population according to Bethesda 2001

Dialysis remains the most common treatment for end-stage renal disease (ESRD). Although the increased risk of cancer after renal transplant is well documented, there is less certainty about the risk of cancer in patients treated only with dialysis. From 1997 to 2002, 262 ESRD patients received a Pap test at Başkent University. The smears of 149 patients who had ESRD for more than 9 months were compared with the smears of 150 otherwise healthy patients. All of the Pap smears were re-examined according to Bethesda 2001 criteria. The mean age of the patients was 42.88 years. Regarding micro-organisms, no statistically significant difference between the groups were observed. In 36 Pap smears, a shift in flora suggestive of bacterial vaginosis was detected. There were statistically significant differences between the groups. When age was considered as a marker of atrophy, atrophy in patients younger than 50 years was statistically different between the groups. Also, we determined that the shift in flora suggestive of bacterial vaginosis and atrophy in patients aged younger than 50 years did not depend on the length of hemodialysis. Of 13 patients (4.3%) who had epithelial cell abnormalities there were not statistically significant differences between the groups. In conclusion, according to our study, CRF seems not to be a predictive factor for cervical cancer. Shift in flora suggestive of bacterial vaginosis and atrophy in patients aged younger than 50 years might be the natural effects of uremia, and they appear not to be dependent on the length of the hemodialysis period.

Occurrence of fungi in water used at a haemodialysis centre

AIMS

The aim of this study was to identify and determine the diversity, occurrence and distribution of fungi in water used at a haemodialysis centre.

METHODS AND RESULTS

Samples in the hydraulic circuit for the distribution of the water, dialysate samples and samples of sterilization solution from dialysers were collected over a 3-month period, and 500 ml of each sample was filtered through membranes. All together 116 isolates of fungi were recovered from 89% of all water samples collected inside the haemodialysis unit, with prevalence of moulds in tap water samples and of yeasts in dialysate samples. Fusarium spp. was the most abundant genus found, whereas Candida parapsilosis was the predominant yeast species.

CONCLUSIONS

This study demonstrated that various fungi were present in the water system. These data suggest the inclusion of the detection and quantification of fungi in the water of haemodialysis.

SIGNIFICANCE AND IMPACT OF THE STUDY

The recovery of fungi from aqueous haemodialysis environments implies a potential risk for haemodialysis patients and indicates the need for continuous maintenance and monitoring. Further studies on fungi in haemodialysis water systems are required to investigate the organism ability to persist, their role in biofilm formation and their clinical significance.

[Isolation of filamentous fungi from water used in a hemodialysis unit]

Despite the relative frequency of opportunistic fungal infections among hemodialysis patients, the reservoirs for these microorganisms in the environment remain unknown, although some recent studies have made correlations with the water supply as their source. The objective of the present study was to monitor the mycological quality of the water system of a hemodialysis unit in the interior of the State of São Paulo, Brazil, over the period from April to July 2006. Fifteen samples of 1000 ml were collected from seven water distribution points using the membrane filtration technique (0.45 microm). A total of 116 filamentous fungus specimens were isolated, including 47 Trichoderma sp (40.5%), 29 Cladosporium sp (25%), 16 Aspergillus sp (13.8%) and 11 Fusarium sp (9.5%). The results suggest that the water supply for hemodialysis units should also be monitored for mycological contamination, and that effective prophylactic measures should be adopted for minimizing the exposure of these immunodeficient patients to contaminated water sources in the environment.

Expanding understanding of epidemiology of coccidioidomycosis in the Western hemisphere

Coccidioidomycosis is a disease of both national and worldwide importance that is most often diagnosed in nonendemic regions. The endemic region for Coccidioides spp. lies exclusively in the Western Hemisphere. Coccidioides spp. has long been identified in semiarid areas of the United States and Mexico, and endemic foci have been described in areas of Central and South America. Infection is usually the result of activities that cause the fungus to become airborne and inhaled by a susceptible host. Underlying medical diseases that affect T cell function are known to increase the risk of disseminated disease and include human immunodeficiency virus, cancer, and disease processes requiring transplantation and its subsequent immunosuppressive agents. In recent years the incidence of the coccidioidomycosis has increased in California and Arizona, which may be partially due to the massive migration of Americans to the Sunbelt states. To date the highest number of cases reported in Arizona was in 2004, when a total of 3,665 cases of coccidioidomycosis was reported, representing a 281% increase since 1997. Statistics on the prevalence and incidence of coccidioidomycosis in Latin America either are fragmentary or simply are not available.

Infectious complications after kidney transplantation: current epidemiology and associated risk factors

BACKGROUND

The impact of newer immunosuppressive and antimicrobial prophylactic agents on the pattern of infectious complications following kidney transplantation has not been well studied.

METHODS

This is an observational study in 127 adult recipients transplanted from 2001 to 2004. Patients received thymoglobulin (ATG) (50%) or basiliximab (50%) for induction and were maintained on mycophenolate mofetil, either tacrolimus (73%) or sirolimus (SRL) (27%), and prednisone (79%). Antimicrobial prophylaxis included perioperative cefazolin, trimethoprim/sulfamethaxazole for six months, valganciclovir for three months and nystatin for two months. Regression models were used to examine the association of various factors with infections.

RESULTS

We observed 127 infections in 65 patients, consisting of urinary tract infection (UTI) (47%), viral infections (17%), pneumonia (8%) and surgical wound infections (7%). UTI was the most common infection in all post-transplant periods. Enterococcus spp. (33%) and Escherichia coli (21%) were the most prevalent uropathogens. Of six patients with cytomegalovirus infection, none had tissue-invasive disease. There were no cases of pneumocystis pneumonia or BK nephropathy. Six patients developed fungal infections. Two deaths due to disseminated Rhizopus and Candida albicans accounted for a 1.5% infection-related mortality. Retransplantation and ureteral stents were independently associated with UTI (OR=4.5 and 2.9, p=0.06 and 0.03, respectively), as were ATG and SRL with bacterial infections (OR=3.3 and 2.5, p=0.009 and 0.047, respectively).

CONCLUSION

This study suggests that the use of newer immunosuppressive agents in recent years is associated with some changes in the epidemiology of post-transplant infections. Enterococci have become the predominant uropathogen. Invasive fungal infections, although rare, are often fatal.

Sinusites fongiques d'origine dentaire. À propos d'une observation chez un hémodialysé chronique

About an observation of aspergillus sinusitis in an hemodialyzed patient, correlation between chronic maxillary sinusitis, its aspergillus origin and previous dental treatments is emphasized. Eventual severe complications then evolved in immunocompromised patients justify having the knowledge of this possible pathology in hemodialyzed and transplanted patients.

Comparison of fungal and nonfungal infections in a broad-based surgical patient population

BACKGROUND

Our aim was to compare fungal and nonfungal infections among a diverse surgical patient population.

METHODS

Data on all hospital-acquired infectious episodes among surgical intensive care unit and ward patients were collected prospectively over six years at a single university hospital. The relationships between fungal and nonfungal infection and over 100 variables were examined using univariate and multiple logistic regression analysis.

RESULTS

During the study period, 3,980 infectious episodes were identified; 554 were associated with fungal infection. Multiple logistic regression analysis demonstrated that markers of severity of acute illness (higher APACHE II scores and white blood cell counts, greater transfusion of cellular blood products, mechanical ventilator dependency, and prior infection) predicted fungal infection, whereas markers of chronic illness (comorbidities) did not independently predict either fungal or nonfungal infection. Patients with fungal infection were treated with more antibiotics for longer periods of time, had prolonged lengths of stay, and more often died compared with nonfungal infection patients. A separate multiple logistic regression analysis demonstrated that both fungal infection and the number of fungal sites of infection independently predicted mortality. Of all fungal isolates, only Candida albicans and Aspergillus spp. independently predicted mortality.

CONCLUSIONS

Fungal infections differ significantly in character and outcomes from nonfungal infections among surgical patients.

An explanation for the increase in heart disease mortality rates in diabetic Pima Indians: effect of renal replacement therapy

OBJECTIVE

Diabetic nephropathy (DN) became the leading cause of death in diabetic Pima Indians in the 1970s, but was superseded by ischemic heart disease (IHD) in the 1980s. This study tests the hypothesis that the rise in the IHD death rate between 1965 and 1998 is attributable to access to renal replacement therapy (RRT).

RESEARCH DESIGN AND METHODS

Underlying causes of death were determined among 2,095 diabetic Pima Indians > or = 35 years old during four 8.5-year time intervals. To assess the effect of access to RRT on IHD death rates, trends were reexamined after subjects receiving RRT were classified as if they had died of DN.

RESULTS

During a median follow-up of 11.1 years (range 0.01-34), 818 subjects died. The age- and sex-adjusted DN death rate decreased over the 34-year study (P = 0.05), whereas the IHD death rate increased from 3.3 deaths/1,000 person-years (95% CI 1.4-5.2) to 6.3 deaths/1,000 person-years (95% CI 4.5-8.0; P = 0.03). After 151 subjects on RRT were reclassified as if they had died of DN, the death rate for DN increased from 4.8 deaths/1,000 person-years (95% CI 2.6-7) to 11.3 deaths/1,000 person-years (95% CI 9-13.6; P = 0.0007), whereas the increase in the IHD death rate disappeared (P = 0.57).

CONCLUSIONS

The incidence rate of renal failure attributable to diabetes has increased rapidly over the past 34 years in Pima Indians. IHD has emerged as the leading cause of death due largely to the availability of RRT and to changes in the pattern of death among those with DN.

Cardiovascular risk in stage 4 and 5 nephropathy

Severity of heart disease of almost all types, as well as mortality risk associated with heart disease, increases in step with severity of kidney disease, although not necessarily in a linear fashion. Heart failure is more common and just as lethal as ischemic heart disease in patients with severe chronic kidney disease (CKD). The incidence of nonfatal heart disease in dialysis and transplant populations has now been described in detail. Although standard risk factors for heart disease that are more common among patients with CKD than in the general population do not adequately explain the greatly increased risk of heart disease in patients with severe CKD, neither do as yet identified "nontraditional" risk factors. However, in addition to the factors not common in the general population, such as anemia, hyperphosphatemia, and markers of systemic inflammation, patients with CKD in the modern era may also exhibit excessive thrombotic tendencies. Screening for heart disease in this population relies mainly on dobutamine stress echocardiography or nuclear scintigraphy. The role of electron beam CT (EBCT) scanning is currently controversial. The indications for coronary angiography are the same for patients with CKD as for the general population, but patients with CKD are at greatly increased risk for contrast-associated nephropathy, the least controversial preventive therapy, which consists of isotonic saline and N-acetylcysteine. Finally, patients with CKD do not currently receive adequate medical therapy for prevention and treatment of heart disease.

Factors associated with improved short term survival in obese end stage renal disease patients

PURPOSE

In contrast to its role in the general population, obesity, defined as body mass index (BMI) > or = 30 kg/m(2), has been associated with improved survival in patients with end stage renal disease (ESRD). This apparent benefit has not been explained.

METHODS

Using the United States Renal Data System (USRDS), we performed an historical cohort study on 151,027 patients initiated on ESRD therapy between January 1, 1995 and June 30, 1997, who never received renal transplants, and who had information sufficient to calculate BMI. We explored the association of various comorbidities present at the time of dialysis initiation (from HCFA Form 2728) with the presence of obesity by logistic regression, and the association of obesity with patient survival, including specific causes of death, by Cox regression adjusting for factors known to be associated with survival in this population.

RESULTS

Obese patients had an unadjusted two-year survival of 68% compared with 58% for non obese patients. Obesity was independently associated with a reduced risk of mortality among chronic dialysis patients (adjusted hazard ratio (AHR) 0.75, 95% confidence interval, 0.72-0.78), after controlling for all comorbidities and risk factors. However, there were significantly adverse interactions among whites (AHR 1.22, 1.14-1.30, across all causes of death) and females (AHR 1.12, 1.04-1.20, entirely due to an increased risk of infectious death).

CONCLUSIONS

Obesity in patients presenting with ESRD is associated independently with reduced all cause mortality; however, the relationship is complex and is stronger in African Americans. In addition, subgroup analysis suggests that obesity is associated with increased risk of infectious death in females.