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Epidemiology of systemic mycoses among renal-transplant recipients in India
George Tharayil John1, Viswanathan Shankar, Girish Talaulikar
1Department of Nephrology, Christian Medical College Hospital, Vellore, Tamil Nadu, India. george@cmcvellore.ac.in
Background:
Systemic mycoses have a high impact on tropical renal-transplant recipients.
Methods:
Data from 1,476 primary renal-transplant recipients was prospectively recorded from 1986 to 2000 at a single center. Cumulative incidence of systemic mycoses, its time of occurrence, risk factors, outcome, and postmortem findings in 30 patients with systemic mycoses were analyzed.
Results:
A total of 110 episodes of systemic mycoses occurred in 98 patients. The fungal genera Aspergillus, Cryptococcus, and Candida constituted 61% of pathogens, 45% localizing to the lungs. Cytomegalovirus (CMV) disease caused a 5-fold and chronic liver disease a 2-fold increase in systemic mycoses. Tuberculosis (TB) with or without nocardiosis was a significant coinfection. Cyclosporine (CsA) was associated with nearly a 4-fold risk of systemic mycoses less than 6 months from the time of transplantation as compared with prednisolone+azathioprine (PRED+AZA) therapy. Overall, the probability of survival with systemic mycoses was 73.4%, 60.8%, 39.5%, and 25.6% and was 92.5%, 87.5%, 80.0%, and 75.5% without systemic mycoses at 1, 2, 5, and 10 years, respectively (P<0.0001). An extended Cox model with time-independent and dependent covariates showed greater than 15 times the risk of death among those who develop systemic mycoses. Similarly, Posttransplantation (postTX) TB+/-Nocardiosis, preTX TB, CMV disease, diabetes mellitus, PTDM, chronic liver disease (>40 months), and Pred+AZA immunosuppression (>2 years) had 3.5, 1.5, 2.9, 1.9, 1.4, 1.6, 2.3 times the risk for death, respectively, as compared with those who did not have those risk factors.
Conclusions:
There is a recent predominance of Aspergillus among the transplant recipients. The risk factors for systemic mycoses are CMV disease, chronic liver disease, and hyperglycemia, and TB is an important coinfection. Systemic mycoses increased in the early postTX period with CsA. The risk factors for death are systemic mycoses, CMV disease, chronic liver disease (>40 months), diabetes mellitus, and Pred+AZA immunosuppression (>2 years). Overall, the probability of survival with systemic mycoses was poor; however, survival has recently improved.
Insights
Systemic mycoses significantly impact tropical renal transplant recipients, with Cytomegalovirus disease and chronic liver disease being key risk factors. Survival rates are poor with mycoses, highlighting the need for improved prevention and treatment strategies.
Area of Science:
- Nephrology
- Infectious Diseases
- Transplantation Immunology
Background:
- Systemic mycoses pose a significant threat to renal transplant recipients in tropical regions.
- Understanding the epidemiology and risk factors is crucial for improving patient outcomes.
Purpose of the Study:
- To analyze the incidence, risk factors, outcomes, and postmortem findings of systemic mycoses in renal transplant recipients.
- To identify specific factors associated with increased risk of mycoses and mortality.
Main Methods:
- Prospective data collection from 1,476 primary renal transplant recipients between 1986 and 2000.
- Analysis included cumulative incidence, timing, risk factors, outcomes, and postmortem data for 30 patients with systemic mycoses.
Main Results:
- 110 episodes of systemic mycoses occurred in 98 patients; Aspergillus, Cryptococcus, and Candida were the most common pathogens.
- Cytomegalovirus (CMV) disease and chronic liver disease significantly increased the risk of mycoses. Tuberculosis (TB) was a common coinfection.
- Cyclosporine (CsA) use was linked to a higher risk of mycoses early post-transplant. Survival probability was significantly lower for patients with systemic mycoses (25.6% at 10 years) compared to those without (75.5%).
Conclusions:
- CMV disease, chronic liver disease, and hyperglycemia are significant risk factors for systemic mycoses in renal transplant recipients.
- Tuberculosis is an important coinfection, and CsA use increases early post-transplant mycoses risk.
- Systemic mycoses drastically increase mortality risk, although recent survival rates show improvement.
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