Cryptococcal Infections in Kidney Transplant Recipients. A Single Center Experience

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Abstract

Introduction

Cryptococcal infections are reported to be an infrequent but important cause of morbidity and mortality in solid organ transplant recipients. Best treatment and the need for secondary prophylaxis are still debated. The aim of this research was to describe incidence, clinical presentation, treatment and outcomes of kidney transplant recipients with cryptococcal infections observed at our institution.

Materials and Methods

Retrospective analysis of cryptococcal infections observed in patients (Pts) transplanted from January 1st 2008 to October 1st 2017. Data on demography, immunosuppression, clinical presentation, treatment and outcome was recollected.

Results and Discussion

1413 transplants were performed in the period 2008-2017. A total of 12 cases of cryptococcal infection was observed (incidence:0.85%). Pts were 3 males/9 females. Age: Median 53.87 (range 20-72) years. Donors were: Deceased: 7 (58.3%); Living related 3 (25 %) Living non-related 2(16.7%.%). Immunosuppression: 10 received induction with timoglobulin. Maintenance immunosuppression: Tacrolimus (FK)- mycophenolic acid (MPA)- prednisone (P): 8 (67%), MPA-P/FK-MPA-P- belatacept/Belatacept MPA-P/and;, sirolimus-FK-MPA-P: 1 each.Four Pts suffered rejections previous to cryptococcal infection (Median time before cryptococcosis: 344.5 (Range: 83-1022) days). Time to infection after transplantation: Median 27.37 (range 3.2-84.3) months. Clinical forms: Meningeal: 6 (50%); Disseminated: 4 (33.3%); Pulmonary: 1 (8.3%); Pleural: 1 (8.3%). Median CD4 count at diagnosis: 88/mm3 (range 47-172). One Pt had a post-mortem diagnosis. Treatment: (Induction): Liposomal Amphotericin B (L-AmB) 9 Pts; L-AmB+Fluconazole: 2 pt. Immunosuppression was temporarily minimized on all Pts until infection was controlled. Consolidation: Fluconazole 11 Pts. (2 pt. still on treatment), 9 pt. completed treatment (median: 12 (range 8,5-20) months,).

Outcomes

All treated Pts (11/11) cured. 9 Pts maintained a functioning graft. Of these, 7 completed treatment (with no secondary prophylaxis) with no relapse of follow-up (FU). Median FU: 13,17 (range 3,44-72,33) months. 2 Pts lost the graft on FU (unrelated to cryptococcosis), and 1 Pt died of unrelated cause.

Conclusion

Treatment with induction with L-AmB (with or without fluconazole), combined with appropriate immunosuppression management was successful in all clinical forms of cryptococcal infection. No relapses were observed in Pts with treatment completed and no secondary prophylaxis.

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