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Epidemiology and Outcomes of Extrapulmonary Invasive Fungal Infections After Kidney Transplantation in Northern India
Abdullah1,2, Anupma Kaul1, Rungmei Marak3
1Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
Background:
Extrapulmonary invasive fungal infections (IFIs) in kidney transplant recipients (KTRs) are understudied, particularly in endemic, resource-limited settings. This study evaluated the epidemiology, risk factors, and outcomes of extrapulmonary IFIs in KTRs in northern India.
Methods:
In this nested case-control study of 1649 KTRs (2007-2022), microbiologically proven extrapulmonary IFI cases were identified from microbiology and histopathology databases.
Results:
Extrapulmonary IFI occurred in 67 KTRs (4.1%). Cryptococcosis (46.3%) and candidiasis (20.9%) were the predominant infections. The central nervous system was the most common site (44.8%), followed by the bloodstream (22.4%). The mean age was 46.78 years, and 85.1% were males. The median time to infection was 55 months posttransplant, and 79.1% of infections occurred beyond 1 year posttransplant. Median estimated glomerular filtration rate (eGFR) was 43 mL/min/1.73 m2, and acute graft dysfunction was present in 49.3% cases. Comorbidities included diabetes (44.8%), chronic renal allograft injury (59.7%), acute rejection (38.8%), bacterial infection (26.9%), and cytomegalovirus disease (13.4%). Diabetes (OR 2.27, p = 0.038) and methylprednisolone pulses for rejection (OR 3.19, p = 0.025) were independently associated with IFI. Infection-related mortality was 35.8%; disseminated infection (HR 3.72, p = 0.020) and requirement for kidney replacement therapy (KRT) (HR 3.98, p = 0.011) independently predicted death. Note that, 5- and 10-year patient survival was significantly lower in cases than in controls (74.1% and 48.3% vs. 92.3% and 74.9%; p = 0.008), whereas death-censored graft survival was comparable.
Conclusions:
Extrapulmonary IFIs are late-onset and commonly present as cryptococcal meningitis or candidemia. Diabetes and methylprednisolone pulses increase infection risk, while dissemination and KRT requirement predict mortality.
Insights
Late-onset extrapulmonary fungal infections are common in kidney transplant recipients, often presenting as cryptococcal meningitis or candidemia. Diabetes and steroid pulses increase risk, while disseminated disease and need for kidney replacement therapy predict mortality.
Area of Science:
- Nephrology
- Infectious Diseases
- Transplantation Immunology
Background:
- Extrapulmonary invasive fungal infections (IFIs) in kidney transplant recipients (KTRs) are understudied, especially in resource-limited regions.
- This study focuses on the epidemiology, risk factors, and outcomes of these infections in northern India.
Purpose of the Study:
- To evaluate the incidence, characteristics, and associated factors of extrapulmonary IFIs in KTRs.
- To identify risk factors and predict mortality in KTRs with extrapulmonary IFIs.
Main Methods:
- A nested case-control study was conducted involving 1649 KTRs from 2007 to 2022.
- Microbiologically confirmed extrapulmonary IFI cases were identified from institutional databases.
Main Results:
- Extrapulmonary IFI occurred in 4.1% of KTRs, predominantly cryptococcosis (46.3%) and candidiasis (20.9%).
- Central nervous system and bloodstream were the most common sites. Infections were often late-onset (median 55 months post-transplant).
- Diabetes (OR 2.27) and methylprednisolone pulses (OR 3.19) were independent risk factors. Mortality was 35.8%, with disseminated infection and need for kidney replacement therapy predicting death.
Conclusions:
- Extrapulmonary IFIs in KTRs are typically late-onset, with cryptococcal meningitis and candidemia being common presentations.
- Diabetes and immunosuppressive therapy (methylprednisolone pulses) are significant risk factors.
- Disseminated infection and the need for kidney replacement therapy are critical predictors of mortality in this population.
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Mode of...