Evaluation of infectious risk and outcomes in the hmong renal transplant population

Abstract

Background: Hmong ethnicity has been associated with infection, particularly fungal.The risk of infection after transplant in the Hmong population is unknown.Methods: Observational study of adult renal transplant (RTX) recipients between 1/1/1994 and 12/31/2015. Primary objective was to identify infectious risk in the Hmong RTX population as compared to non-Hispanic whites (NHW). Secondary objective was to evaluate transplant outcomes. Results:There was a total of 2599 patients in the study window; 95 Hmong, 2504 NHW. The Hmong population had significantly fewer bacterial and fungal infections at 1 and 3 years (Bacterial: Hmong 21.7%, 32.4% vs NHW 36.9%, 46.7%, P = .004; Fungal: Hmong 3.3%, 5.7% vs NHW 12.7%, 16.6%, P = .0005) and improved graft and patient survival at 1, 5, and 10 years (Graft: Hmong 92.6%, 78.4%, 61.9% vs NHW 90.7%, 72.2%, 48.5%, P = .006; Patient: Hmong 97.8%, 94.5%, 83.3% vs NHW 95.3%, 82.1%, 62.1% P < .001). Spectrum of bacterial infection was similar, but with significantly more Staphylococcal infection in the NHW population. Blastomycoses were the major fungal pathogen in Hmong (2/3, 67%) vs Candida in NWH (77%).When minimally adjusted for PRA and age, rates of bacterial infection (HR 0.69, 95% CI 0.48-0.99, P = .047), fungal infection (HR 0.39, 95% CI 0.17-0.87, P = .02), and mortality (HR 0.5, 95% CI 0.28-0.88, P = .02) were more favorable in the Hmong population. When analyzed in a stepwise Cox proportional hazards model; Hmong ethnicity was not a significant risk factor for graft failure, rejection, CMV, BK, or fungal infection after RTX and was associated with reduced risk of bacterial infection (HR 0.61, 95% CI 0.4-0.9, P = .02) and mortality (HR 0.51, 95% CI 0.27-0.96, P = .04). Conclusions:Despite concern regarding infective risk in the Hmong population, infection after RTX is no higher than NHW comparator. In all analyses, the Hmong population has equal or better outcomes. It does not appear variance in standard infection prophylaxis is necessary for the Hmong population after RTX.

Long-Term Infectious Complications of Kidney Transplantation

“…Pneumonia has been reported in 80% of kidney transplant with blastomycoses, and disseminated disease commonly includes cutaneous manifestations (82). Risk for blastomycosis in kidney transplant is difficult to assess outside of environmental exposure given the relatively infrequent events; one study from Wisconsin identified two of three cases developed in a minority population, the Hmong (87). Similar to histoplasmosis, diagnosis focuses on direct visualization or culture from sputum, BAL, or tissue.…”

Transplantation and immigration: Comparing infectious complications and outcomes between foreign‐born and US‐born kidney transplant recipients in Minnesota

“…Jorgenson et al 12 compared the rates of infections between Hmong and non-Hispanic White KTRs during the first-year post-transplant and found that BK infection (6.7% vs. 9.1%, p = .84) was less frequent in Hmong patients although the difference was not statistically significant. In contrast to our study, Hmong patients were selected based on ethnic group but not separated into foreign versus US-born.…”

“…However, this expanded screening for these latent infections is not standardized and may be potentially insufficient for early detection and appropriate management of RIM patients. Although previous studies in pediatric and adult RIM kidney transplant recipients (KTRs) have demonstrated similar outcomes of graft function and mortality compared to US‐born KTRs (USKTR), none of these studies have reported detailed information about the type and timing of infectious episodes 3,12–15 . More granular data could guide and improve the prevention, diagnostics, and treatment of post‐transplant infections, especially for foreign‐born KTRs (FBKTR).…”

“…Although previous studies in pediatric and adult RIM kidney transplant recipients (KTRs) have demonstrated similar outcomes of graft function and mortality compared to US-born KTRs (USKTR), none of these studies have reported detailed information about the type and timing of infectious episodes. 3,[12][13][14][15] More granular data could guide and improve the prevention, diagnostics, and treatment of post-transplant infections, especially for foreign-born KTRs (FBKTR). This study compares the frequency and etiology of infectious complications and outcomes between FBKTR and USKTR in two large transplant centers in the state of Minnesota.…”