The Clinical Analysis Of The Patients Concurrent With Invasive Pulmonary Fungal Infections After Kidney Transplantation

Research backgroundKidney transplantation is the most effective treatment of the end stage renal disease,However,with the extensive use of the new immunosuppressant and the broad-spectrum antibiotic,the deep fungal infection of the post-operation patients has become one of the key factors of the graft function' loss and the patients'deaths. The Invasive Pulmonary Fungal Infections (IPFI) ranks first among the deep fungal infection. Beacause IPFI has no obvious clinical characteristic,it is difficult to diagnose and easy to misdiagnose in the early stage.Although there has been an improvement in diagnosis and treatment, the mortality rate remains at a high level.TRANSNET of the US once monitored 8,672 patients after kidney transplatation of 23 organ transplantation centers in 5 years, which indicated that the morbidity rate of the IPFI after kidney transplantation accounted for 23.8%;the one year livability of the Aspergillus infection accounted for 59%;the one year livability of the Monilia infection accounted for 66%;the one year livability of the Cryptococcus infection accounted for 73%.India reports that the morbidity rate of the IPFI after renal transplantation accounted for 1.4%-9.4%, with the mortality rate of 30%-70%. The domestic single center reported that the mortality rate of the IPFI accounted for 39.8%.The current research shows that the main pathogenic fungi of IPFI after kidney transplantation is conditioned pathomycete.TRANSNET of the US indicated that among the IPFI paticents, the most important pathogenic fungi was the Monilia(53%), and then was the invasive Aspergillus (19%), after that was the Cryptococcus(8%),the non-invasive Aspergillus (8%),the local fungal infection(5%),the Zygomycete(2%).The domestic single center reported that the proportion of pathogenic fungi of IPFI:Candida albicans(51.8%),Candida glabrata (19.2%),Candida tropicalis(14.5%),Aspergillus(7.2%),Mucor(2.4%),Cryptococcus (2.4%),Pneumocystis(2.4%)。At present,the domestic report of the IPFI is often about fungal infection with the tumor patients,the ICU patients and the patients with the life-support machines. In recent years, the IPFI after kidney transplantation has drawn the clinicians'attention for the high infection rate,high mortality rate and low diagnosis rate.The mortality rate of the IPFI after the kidney transplantation is hard to be confirmed for the possible mixed factors. There is only few centers in our country do some similar researches,and their reports only focus on the risk factors of the IPFI. Moreover, at present, there is no a specific clinic index for evaluating the prognosis of IPFI.Therefore, at present, the IPFI after kidney transplantation is still a big trouble for the clinicians.ObjectiveTo investigate the clinical features of the patients concurrent with Invasive Pulmonary Fungal Infections (IPFI) after kidney transplantation, analysis on the prognosis factors which impact on the IPFI patient and find a specific clinic index for evaluating the status of the diagnosis and treatment of IPFI. MethodsA retrospective study was undenaken in 80 cases diagnosed as invasive pulmonary fungal infections after kidney transplantatinon in Zhujiang Hospital from January lst,2000 to April 1st 2010. Patients were divided into two groups according to death or survive during hospitalization.The following data were collected for each patient: age,gender,clinical features of the IPFI,pathogen,treatment effects and side effects of antifungal drug, chest X-ray or CT characteristics, CPIS(clinical pulmonary infection score) at the dayl of infection,CPIS at the day 5 after antifungal treatment,etc.by univariate analysis and multivariate Logistic regression analysis,to figure out the factors related to prognosis and the whether the CPIS is the appropriate clinic index of the IPFI.Results80 cases were diagnosed as IPFI after kidney transplantation,54 were males and 26 were females, The mean age is(47.21±10.479)y; there are 47 cases(58.8%) get the infection between 1-3m after the operation,17 cases(21.2%) between 3-6m,3 cases (3.8%) between 6-12m and 13 cases (16.2%) more than 12m.The result of chest imaging findings:exudative lesions 28 cases(26.42%),cavity 1 case(0.94%),nodules 11 cases(10.38%),clump 4 cases(3.77%),interstitial lesions 42 cases (39.62%),pleural effusion 12 cases (11.32%) and consolidation 8 cases (7.55 %).Concurrent pneumocystis infection was the most frequent diagnosis(40%), followed by Candida albicans infection(26.25%)and Aspergillus infection(20%).Of all the cases,40(50%)were possible diagnosis,28(35%)were probable diagnosis and 12 (15%) were proven diagnosis.69 strains of fungi were isolated from 80 patients, and There are 39 strains of Candida albicans, accounting for 56.52%; followed by Aspergillus,11 strains, accounting for 15.94% and Candida krusei 9 strains,accounting for 13.4%;The mortality rate of IPFI of our research is 30%; 50% of the 80 patients selected sulfamethoxazole as antifungal drug and their effective rate were 72.13%, for AmphotericinB liposomes were 12.29% and 66.67% respectively, for Fluconazole were 25.41% and 48.39%, voriconazole were 2.46% and 85.71%, For Micafungin were 9.84% and 25%.The mean time of the antifungal therapy during hospital were 14.81 days.The CPIS of dayl in the death group is (4.04±2.053), in the survive group is (3.89±1.796), and this was not statistically significant difference (t=0.325, P=0.595); CPIS of day5 in the death group is (7.96±2.116), in the survive group is (1.93±1.971), and there was statistical significance difference (t=12.266,P=0.000)。Univariate analysis showed that body temperature (x2=5.079, P=0.024), fasting blood glucose(x2=10.430, P=0.001), renal insufficiency (x2=9.267, P=0.002), malnutrition (x2=9.267, P=0.002), the onset time of infection after transplantation (X2=7.979, P=0.046), the CPIS level lowed at day 5 (x2=64.292, P=0.000) and mechanical ventilation (x2=5.873, P=0.000),7 factors are impacted on the prognosis of the patients concurrent with IPFI after kidney transplantation. Logistic regression analysis showed that the renal insufficiency(OR=18.096), mechanical ventilation (OR=130.7) and lowed CPIS at day 5 (OR=0.011) are independent prognosis factors, inwhich the lowed CPIS at day 5 is a protective factor.Conclusions1. The the morbidity rate of IPFI of our research is 5.3% and the mortality rate is 30%, Concurrent pneumocystis(40%),Candida albicans(26.25%) and Aspergillus (20%)remain the most commonly identified IPFI among kidney transplantation patients in our center. 2. The chest imagings are complex and varied, it will be wrong to diagnosed only by some special images.3. Voriconazol is a new antifungal medicine, with very effective and fewer adverse reaction in our research.4.The CPIS is a specific clinic index for evaluating the prognosis of invasive pulmonary fungal infection.5.There are multiple variables associated with survival in kidney transplantation patients with IPFI.If empirical therapy,advanced renal replacement therapy are given timely and rationally, and anti-fungal therapy protocol adjusted according to the CPIS on the 5th day, it may be assist in improving the prognosis of the patients.