Analysis of USRDS: Incidence and Risk Factors for Pneumocystis jiroveci Pneumonia
ABSTRACT To investigate the effect of modern immunosuppression on the incidence, risk factors, morbidity, and mortality of Pneumocystis pneumonia (PCP) in recipients of kidney transplants.
We conducted a retrospective cohort study of 32,757 Medicare primary transplant recipients in the United States Renal Data System from January 1, 2000 through July 31, 2004. PCP infection was defined by Medicare claims using International Classification of Disease, 9th Revision codes. The incidence of PCP infections, graft loss, and death were measured.
There were a total of 142 cases (cumulative incidence 0.4%) of PCP after kidney transplantation during the study period. By using multivariate analysis with Cox regression, expanded criteria donor, donation after cardiac death, and earlier year of transplant were associated with development of PCP disease. Induction immunosuppression and acute rejections were not associated with risk for PCP infections. However, based on adjusted hazard ratio (AHR), maintenance immunosuppression regimens containing the combination of tacrolimus and sirolimus (AHR 3.60, confidence interval [CI] 2.03-6.39), Neoral and mycophenolate mofetil (AHR 2.09, CI 1.31-3.31), and sirolimus and mycophenolate mofetil (AHR 2.77, CI 1.40-5.47), were associated with development of PCP. As a time dependent variable, PCP was associated with an increased risk of both graft loss and death.
PCP infections are rare in the modern era of prophylaxis; however, these infections are a serious risk factor for graft loss and patient death, in particular, in patients who are on sirolimus as part of the immunosuppressive regimen. The median time to development of PCP after transplant was 0.80+/-0.95 years, suggesting a longer period of PCP prophylaxis.
- SourceAvailable from: PubMed Central
[Show abstract] [Hide abstract]
- "In Southeast Asia, PCP prevalence among HIV-infected children and adults with pneumonia has been reported to be as high as 66% , , . Among HIV-uninfected persons, those at risk of PCP include persons receiving immunosuppressive therapies, such as renal transplant patients (estimated cumulative PCP incidence: 0.4%) , , patients undergoing immunosuppressive therapy for connective tissue disorders , and children with chronic lung diseases . Mortality from PCP among HIV-uninfected patients can be as high as 40% . "
ABSTRACT: Diagnosis of Pneumocystis jirovecii pneumonia (PCP) is challenging, particularly in developing countries. Highly sensitive diagnostic methods are costly, while less expensive methods often lack sensitivity or specificity. Cost-effectiveness comparisons of the various diagnostic options have not been presented. We compared cost-effectiveness, as measured by cost per life-years gained and proportion of patients successfully diagnosed and treated, of 33 PCP diagnostic options, involving combinations of specimen collection methods [oral washes, induced and expectorated sputum, and bronchoalveolar lavage (BAL)] and laboratory diagnostic procedures [various staining procedures or polymerase chain reactions (PCR)], or clinical diagnosis with chest x-ray alone. Our analyses were conducted from the perspective of the government payer among ambulatory, HIV-infected patients with symptoms of pneumonia presenting to HIV clinics and hospitals in South Africa. Costing data were obtained from the National Institutes of Communicable Diseases in South Africa. At 50% disease prevalence, diagnostic procedures involving expectorated sputum with any PCR method, or induced sputum with nested or real-time PCR, were all highly cost-effective, successfully treating 77-90% of patients at $26-51 per life-year gained. Procedures using BAL specimens were significantly more expensive without added benefit, successfully treating 68-90% of patients at costs of $189-232 per life-year gained. A relatively cost-effective diagnostic procedure that did not require PCR was Toluidine Blue O staining of induced sputum ($25 per life-year gained, successfully treating 68% of patients). Diagnosis using chest x-rays alone resulted in successful treatment of 77% of patients, though cost-effectiveness was reduced ($109 per life-year gained) compared with several molecular diagnostic options. For diagnosis of PCP, use of PCR technologies, when combined with less-invasive patient specimens such as expectorated or induced sputum, represent more cost-effective options than any diagnostic procedure using BAL, or chest x-ray alone.PLoS ONE 08/2011; 6(8):e23158. DOI:10.1371/journal.pone.0023158 · 3.23 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Antiretroviral therapy and cotrimoxazole prophylaxis have caused a decline in Pneumocystis jirovecii incidence in developing countries since the 1990s. Nevertheless, Pneumocystis jirovecii pneumonia (PCP) remains the primary AIDS-defining disease around the world. Much about the disease remains unknown, including its global burden, best diagnostic practices, the frequency of drug resistance, and the risks associated with Pneumocystis colonization. This review describes current knowledge about Pneumocystis infection and highlights areas where new research could benefit public health. Keywords Pneumocystis -PCP- Jirovecii - Carinii -Pneumonia-HIV-Immunosuppressed-Fungal-DHPS-Colonization-Prophylaxis-Oral washesCurrent Fungal Infection Reports 12/2010; 4(4):229-237. DOI:10.1007/s12281-010-0029-3
- [Show abstract] [Hide abstract]
ABSTRACT: High resolution oversampling analog-to-digital and digital-to-analog converters are proposed. These converters utilize novel multi-stage noise shaping modulation techniques which can be implemented with fine pattern MOS technology. The modulators consist of multi-connected delta sigma modulation loops with single integration. The quantization noise in the first loop is re-quantized by the second loop. That is, the noise is canceled by adding the second loop output signals to the first loop output. The resolution of the modulators increases in proportion to the number of stages and there are no feedback-loop stability problems. An experimental prototype chip is fabricated using 1.5µm CMOS technology. This chip achieves a wide dynamic range of 88dB at a baseband of 3.4KHz and sampling rate of 2.048MHz. This dynamic range corresponds to a 14-bit equivalent resolution.Acoustics, Speech, and Signal Processing, IEEE International Conference on ICASSP '86.; 05/1986