Invasive Aspergillosis after Renal Transplantation

Abstract

Over 95,000 renal transplantation procedures were completed in 2021. Invasive aspergillosis (IA) affects about 1 in 250 to 1 in 43 renal transplant recipients. About 50% of cases occur in the first 6 months after transplantation; the median time of onset is nearly 3 years. Major risk factors for IA include old age, diabetes mellitus (especially if prior diabetic nephropathy), delayed graft function, acute graft rejection, chronic obstructive pulmonary disease, cytomegalovirus disease, and neutropenia. Hospital construction, demolition activities, and residential refurbishments also increase the risk. Parenchymal pulmonary infection is the most common (~75%), and bronchial, sinus, cerebral, and disseminated disease are less common. Typical pulmonary features of fever, dyspnea, cough, and hemoptysis are seen in most patients, but 20% have non-specific general features of illness. Non-specific infiltrates and pulmonary nodules are the commonest radiological features, with bilateral disease carrying a worse prognosis. Bronchoscopy for direct microscopy, fungal culture, and Aspergillus antigen are the fastest means of establishing the diagnosis; a positive serum Aspergillus antigen presages a worse outcome. Standard therapy includes voriconazole, isavuconazole, or posaconazole, with great attention necessary to assess likely drug–drug interactions. Liposomal amphotericin B and echinocandins are less effective. A reduction in or stopping immunosuppression needs careful consideration, given the overall mortality of IA in renal-transplanted patients; continuing corticosteroid after the diagnosis of IA increases mortality by 2.5 times. Surgical resection or the addition of a gamma interferon should also be considered.

The Impact of Corticosteroids on the Outcome of Fungal Disease: a Systematic Review and Meta-analysis

“…We have not addressed the likely impact of azole/corticosteroid interactions, which may have acted to effectively boost corticosteroid exposure, in those taking prednisolone and voriconazole and methylprednisolone and itraconazole, as examples. Moreover, no study reported renal transplant loss related to withdrawal or not of corticosteroid therapy in the context of life-threatening fungal infection [112]. Future research could focus on the impact of corticosteroids on the outcome in renal transplant recipients and explore if reduction in steroid dose could have a positive impact on retaining renal allografts, without the patient dying.…”

Invasive pulmonary aspergillosis following human metapneumovirus infection in solid‐organ transplant recipients: Another virus to add to the list

“…9 Almost half of the cases (43%) occur in the first 6 months after transplantation, with a mortality of 40%-60%; 20%-25% of those who survive present graft loss. 8 HMPV in the SOT population causes 1.5-16.3 cases of respiratory infection per 1000 patients per year, representing 4.5% of all RVI. Cough and upper respiratory symptoms are common, and disease progression to pneumonia in a median of 7 days is common (49% of cases).…”

Persistent fever after coronavirus disease 2019 in liver/kidney transplant recipient

“…Aspergillus infection has also been frequently described as associated with COVID‐19 15 . While a negative serum Aspergillus galactomannan can occur in the setting of a positive (1,3)‐β‐D‐glucan, the imaging is not typical in this case 17 . Yet, if this was a significant concern, a bronchoscopy with bronchoalveolar lavage (BAL) Aspergillus galactomannan could be helpful.…”