Clinical Manifestation And Relationship Between Immune Function And Prognosis Of Pneumocystis Pneumonia In Chronic Renal Disease Patients With Secondary Immunodeficiency

Background and objectiveThe disease known as Pneumocystis pneumonia(PCP)is caused by the ascomystis fungus Pneumocystis jirovecii(PJP),which is one of the leading causes of illness and death in persons infected with human immunodeficiency virus(HIV).In recent years,increasing number of organ transplantation patients and immunosuppressive drugs used more commonly,in higher doses,or in combinations may have increased the susceptibility of non-HIV patients to PJP infection.The ratio of non-HIV versus HIV patients presenting PCP increased from 1.7 to 5.6 during the year 2003 to 2015.What is more,the mortality rate of non-PCP patients with secondary PCP was significantly higher than that of HIV patients,while non-HIV patients were less symptomatic at diagnosis than HIV patients.At present,the domestic and foreign studies on non-HIV patients with PJP infection are mainly limited to patients with hematological diseases,solid tumors and rheumatoid diseases which accept immunosuppressive therapy.However,data on occurrence and risk factors for PCP in patients with renal disease remain sparse.Therefore,this study analyzed the clinical data of PCP in patients with secondary immune deficiency in kidney disease,and discussed the relationship between immune function and prognosis,in order to increase physician' sexperience with this disease,improve the diagnostic suspicion of PJP in non-HIV-patients,select of optimal agents promptly,and finanally reduce the mortality.MethodsThis is a retrospective analysis.A search of intensive care unit of National clinical research center of kidney diseases Jinling Hospital,between October 7 2013 and May 15 2017,demonstrates 52 cases of the patients who received immunosuppressive therapy for renal diseases with clinical PJP infection.Clinical and laboratory data such as gender,age,the underling diseases,the administration history of glucocorticoid and immunosuppressant,hospitalization time,clinical manifestations at onset,chest imaging results,oxygenation function,lymphocyte count,peripheral blood CD4+ T-cell count and SOFA score were collected.Procalcitonin,fungal G test,lactate dehydrogenase,treatment cost,therapeutic outcome and so on.According to the prognosis,the patients were divided into death group and improved group.The clinical characteristics,risk factors,especially the relationship between immune function and prognosis were analyzed.ResultsAmong the 52 cases,14 were renal transplantation recipients.of them had received immunosuppressive treatment and circulating CD4+ lymphocyte count were below 200/?l.All of them had received corticosteroid therapy,17 patients had been administered corticosteroids only,17 had been administered corticosteroids with one immunosuppressant agent,the rest had been combined corticosteroids with several immunosuppressant agents.35 cases had been receiving or enhancing immunosuppressive treatment for 2-4 months before infection.All Clinical presentations of onset were mainly chest stuffiness and fever.The chest radiographic images of all the patients showed bilateral,symmetric,reticular or granular opacities,and serum(1-3)?-D-glucan(BDG)levels were all above normal.Procalcitonin(PCT)were normal in 20 patients,increasing slightly in 21 patients,increasing obviously only in 11 patients.13 patients dead while 39 recovered after treatment.Single factor regression analysis showed renal transplantation lower CD4+ lymphocyte count,increased BDG and severe acute respiratory distress syndrome(ARDS)were related with bad outcome of this disease.Multivariate logistic regression analysis revealed that lower CD4+ lymphocyte count,increased BDG and severe ARDS were prognostic factors of PCP.Receiver operating characteristic(ROC)curve indicated that CD4+ lymphocyte count>64/?l predicted satisfactory outcome.Covariance analysis of repeated sequencing variables showed the lymphocyte count persisted lower in the first 6 days after hospitalization indicated poor prognosis.ConclusionsIn summary,PCP was not unusual in kidney-disease patients receiving immunosuppressive treatment.69%of the cases had been receiving or enhancing the immunosuppressive therapy for about 3 months before infection.Non-specific respiratory symptoms is the primary manifestation of PCP,especially in early stage.Typical chest radiographic images and high BDG were contribute to diagnosis.Lower CD4+ count,increased BDG and severe ARDS indicated poor prognosis.Immune state and its reconstructive ability were important factors affecting the prognosis.