<p>Clinical Characteristics of <em>Pneumocystis</em> Pneumonia After Parental Renal Transplantation</p>

Abstract

To analyze the clinical characteristics of Pneumocystis pneumonia (PCP) in renal transplant recipients, identify early sensitivity indicators, and optimize clinical strategies. Patients and Methods: We retrospectively analyzed clinical data for 24 patients with confirmed PCP who underwent renal transplantation (RT) between 2010 and 2019, encompassing a mean follow-up of 29 (range, 11-49) d. Results: A 71% incidence was observed for PCP during the first 6 months after RT. Progressive dyspnea (79%) was the most common symptom, followed by fever (75%) and dry cough (67%). In the initial phase of PCP, the most frequent computerized tomography (CT) finding was the presence of symmetric, apically distributed ground-glass opacities. Nine of 11 patients (82%) were diagnosed by induced sputum testing, 14 of 17 (82%) by bronchoalveolar lavage, and 1 of 24 (4%) by sputum smear. The 1,3-β-D-glucan level was elevated (mean, 259.16 ± 392.34 pg/mL) in 80% of patients, while 75% had elevated C-reactive protein levels (median, 37.85 mg/L). Two of 18 patients (11%) were positive for cytomegalovirus. All patients were treated with trimethoprim-sulfamethoxazole (3 doses of 1-6 g/kg) and thirdgeneration cephalosporin or moxifloxacin monotherapy to prevent bacterial infection. The methylprednisolone dose (40-400 mg/d) varied according to illness. Most patients were treated using a nasal cannula or oxygen mask, and 2 by mechanical ventilation. CT showed improved lesions after treatment, and completely absorbed lesions or residual fibrosis at follow-up. The mean hospitalization cost was 14,644.73 ± 11,101.59 RMB. Conclusion: Peak PCP incidence occurred during the first 6 months after surgery. Progressive dyspnea, fever, and dry cough are important indicators for PCP. Bilateral and diffuse ground-glass opacities involving both lung apexes are often the first indication for PCP diagnosis. Induced sputum testing may be the method-of-choice for pathogen detection. The cure rate can be improved through early antipathogen, glucocorticoid, and preventive anti-infection therapies, as well as respiratory support.

Efficacy of Low-Dose Trimethoprim/Sulfamethoxazole for the Treatment of Pneumocystis jirovecii Pneumonia in Deceased Donor Kidney Recipients

“…10 Similarly, when Li et al gave patients oral TMP-SMX therapy at a dose of 1-6 g/kg divided over three administrations, the dosage of SMX was later reduced due to adverse reactions in some patients. 9 Some published studies reported poor tolerability and high discontinuation rates even when SMX-TMP was used at 1 single-strength tablet daily as PJP prophylaxis in kidney transplant recipients. [22][23][24] In the present study, all the eligible patients were treated with TMP-SMX 480/2400mg or 240/1200mg per day divided into three doses, and only 21.6% (8/37) of the patients experienced gastrointestinal symptoms, 5.4% (2/37) suffered hematologic side effects, 2.7% (1/37) developed hyperkalemia, and 2.7% (1/37) experienced transient impairment in kidney function.…”

“…According to previous reports, the incidence of PJP was highest within 6 months after renal transplantation after intensifying immunosuppression. 5 , 9 The Kidney Disease Improving Global Outcomes (KDIGO) and Kidney Health Australia Caring for Australians with Renal Impairment (KHA-CARI) guidelines recommend administering TMP-SMX for 3–6 months after kidney transplantation to prevent PJP. 12 , 13 In the present study, all recipients received TMP-SMX as PJP prophylaxis for 6–12 months (86.5% of the patients received TMP-SMX for 6 months) unless severe leukopenia or kidney dysfunction (serum creatinine level exceeding 2 mg/dl) were present.…”

“…The most common adverse events following SMX-TMP treatment are hematological side effects, renal or hepatic dysfunction, and gastrointestinal discomfort. 9 Tu et al treated two cases of PJP in renal transplant recipients with TMP-SMX at the initial dose of 240/1200 mg q8h, but the dose was reduced to 80/400 mg tid in one case because of hepatic dysfunction and in the other case due to leukopenia. 10 Similarly, when Li et al gave patients oral TMP–SMX therapy at a dose of 1–6 g/kg divided over three administrations, the dosage of SMX was later reduced due to adverse reactions in some patients.…”

“… 20 However, in clinical practice, adjunctive glucocorticoids are often administered as soon as possible in most cases with an abrupt onset and poor prognosis. 9 , 10 In the present study, all 37 PJP patients were treated with methylprednisolone 20–40 mg twice daily during the early stage of the disease, instead of waiting until severe hypoxia. The results were good, and only 5.4% (2/37) of the patients later required invasive ventilation.…”

“…Li et al reduced the dose of TMP-SMX for renal transplant recipients with PJP that experienced intolerable gastrointestinal side effects and still achieved a high recovery rate of 83%. 9 Similarly, Tu et al successfully treated three cases of severe PJP in renal transplant recipients with combination caspofungin and low-dose TMP-SMX (480 mg q8h). 10 In the absence of randomized controlled trials, the optimal dosage of TMP-SMX in PJP remains unknown, and the existing literature reports conflicting results.…”