The Diagnosis of Pneumonia in Renal Transplant Recipients Using Invasive and Noninvasive Procedures

doi:10.1378/chest.125.2.541

Chest

Volume 125, Issue 2, February 2004, Pages 541-547

https://doi.org/10.1378/chest.125.2.541 Get rights and content

Study objectives

We used invasive and noninvasive procedures to determine the causes of pneumonia in renal transplant recipients.

Subjects and methods

We retrospectively surveyed 565 renal transplant recipients (transplants received March 1984 to August 2001) to find those with pneumonia. Noninvasive diagnostic methods included serologic testing, and blood and sputum cultures with stains. Invasive procedures included fiberoptic bronchoscopy and percutaneous transthoracic procedures.

Results

A total of 92 patients were enrolled. Of these, 71 patients had a definite etiologic diagnosis of pneumonia. The major infectious pathogens were bacterial (n = 21) and mixed bacterial infection (n = 10), Mycobacterium tuberculosis (TB) [n = 18], and fungi (n = 8). Noninvasive and invasive procedures led to the diagnosis of pneumonia in 31.5% (n = 29) and 45.6% (n = 42) of patients, respectively. Bronchoscopy was used in 64 patients, with a diagnostic yield of 38 cases (59.3%). Patients were 3.62 times more likely to contract pneumonia within 12 months of renal transplantation than they were ≥ 12 months thereafter (95% confidence interval, 1.33 to 9.84). Twenty-seven of the 92 patients (29.3%) died. The pneumonia mortality rate has dropped significantly since 1996 (41.8% vs 10.8%, p = 0.002).

Conclusion

Both invasive and noninvasive procedures are useful in the diagnosis of pneumonia, with declining mortality, in renal transplant recipients. Bacterial and mixed bacterial infection, TB, and fungal infection are the most common pathogens; cases are most likely to occur within 1 year after renal transplantation.

Section snippets

Patients

All 565 renal transplant recipients (transplants received between March 1984 and August 2001) at Taichung Veterans General Hospital, a teaching hospital and tertiary referral center at Taichung, Taiwan, were surveyed. We retroactively studied all episodes of fever, cough, and new pulmonary infiltrates in these patients from the beginning of transplantation to the day of graft failure or patient mortality. All of the patients received prophylactic antibiotics with trimethoprim-sulfamethoxazole

Results

Of the 565 patients (330 men and 235 women; mean age, 40.0 ± 11.7 years [mean ± SD]), 92 patients had episodes of pneumonia (58 men and 34 women; mean age, 42.2 ± 13.6 years). The median follow-up period of these 565 patients was 81.0 ± 46.1 months (range, 1 to 209 months). Initially, 106 patients had pulmonary infiltrates; of these, 14 patients were excluded due to acute pulmonary edema combining with other infections (n = 12) and diffuse pulmonary hemorrhage (n = 2). In the remaining 92

Discussion

The choice of a diagnostic procedure in immunocompromised patients must be based on the yield for the most likely pathogens and the safety of the procedure. Sputum should be obtained from renal transplant patients with pneumonia because it is easily done, although BAL or biopsy provides a more accurate means of diagnosis. Open lung biopsy (OLB) is considered the “gold standard” for evaluation of lung infiltrates in the immunocompromised host. In the report by White et al,⁶ OLB in patients with

ACKNOWLEDGMENT

We thank Dr. Michael S. Niederman for the review of this manuscript.

References (39)

A Xaubet et al.
Pulmonary infiltrates in immunocompromised patients: diagnostic value of telescoping plugged catheter and bronchoalveolar lavage
Chest
(1989)
JJ Griffin et al.
New approaches in the diagnosis of nosocomial pneumonia
Med Clin North Am
(1994)
A Torres et al.
Etiology and microbial patterns of pulmonary infiltrates in patients with orthotopic liver transplantation
Chest
(2000)
RI Sternberg et al.
Utility of bronchoalveolar lavage in assessing pneumonia in immunosuppressed renal transplant recipients
Am J Med
(1993)
BA Collin et al.
Pneumonia in the compromised host including cancer patients and transplant patients
Infect Dis Clin North Am
(1998)
RP Baughman et al.
The continuing utility of bronchoalveolar lavage to diagnose opportunistic infection in AIDS patients
Am J Med
(1994)
M Tamm et al.
Pulmonary cytomegalovirus infection in immunocompromised patients
Chest
(2001)
G Cathomas et al.
Rapid diagnosis of cytomegalovirus pneumonia in marrow transplant recipients by bronchoalveolar lavage using the polymerase chain reaction, virus culture, and the direct immunostaining of alveolar cells
Blood
(1993)
RH Rubin
Infectious disease complications of renal transplantation
Kidney Int
(1993)
E Gane et al.
Randomised trial of efficacy and safety of oral ganciclovir in the prevention of cytomegalovirus disease in liver-transplant recipients: The Oral Ganciclovir International Transplantation Study Group
Lancet
(1997)

M Pascual et al.

Strategies to improve long-term outcomes after renal transplantation

N Engl J Med

(2002)

RP Baughman

The lung in the immunocompromised patient: infectious complications; part 1

Respiration

(1999)

M Tamm

The lung in the immunocompromised patient: infectious complications; part 2

Respiration

(1999)

M el-Ebiary et al.

Quantitative cultures of endotracheal aspirates for the diagnosis of ventilator-associated pneumonia

Am Rev Respir Dis

(1993)

DA White et al.

The utility of open lung biopsy in patients with hematologic malignancies

Am J Respir Crit Care Med

(2000)

WC Waltzer et al.

Open-lung biopsy in the renal transplant recipient

Surgery

(1980)

HW Haverkos et al.

Diagnosis of pneumonitis in immunocompromised patients by open lung biopsy

Cancer

(1983)

RP Baughman

Use of bronchoscopy in the diagnosis of infection in the immunocompromised host

Thorax

(1994)

JE Thorpe et al.

Bronchoalveolar lavage for diagnosing acute bacterial pneumonia

J Infect Dis

(1987)

Cited by (65)

Evaluation of the Renal Transplant Recipient in the Emergency Department
2019, Emergency Medicine Clinics of North America
Is hospital-acquired pneumonia different in transplant recipients?
2019, Clinical Microbiology and Infection
Citation Excerpt :
In this line, the data available from the RESITRA study showed an overall mortality of 46.3% in allo-HSCT, with 66% of these deaths considered to be related to pneumonia [17]. The reported mortality rates of nosocomial pneumonia in SOT recipients have been as high as 50–70% [30,43–46]. In PT recipients mortality varies from 14% to 40% depending on whether HAP or VAP is considered [25,47].
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are serious complications in transplant patients. The aim of this review is to summarize the evidence regarding nosocomial pneumonia in transplant recipients, including HAP in non-ventilated patients and VAP, and to identify future directions for improvement.A comprehensive literature search in the PubMed/MEDLINE database was performed. Articles written in English and published between 1990 and November 2018 were included.
HAP/VAP in transplant patients usually occurs early post-transplant, particularly during neutropenia in haematopoietic stem cell transplant recipients. Bacteria are the leading cause of nosocomial pneumonia for both immunocompetent and transplant recipients, being Gram negative organisms, and especially Pseudomonas aeruginosa, highly prevalent. Multidrug-resistant bacteria are of special concern. Pneumonia in the transplant setting may be caused by opportunistic pathogens, and the differential diagnosis needs to be extended to other non-infectious complications. The most relevant opportunistic pathogens are Aspergillus fumigatus, Pneumocystis jirovecii and cytomegalovirus. Nevertheless, they are an exceptional cause of nosocomial pneumonia, and usually occur in severely immunosuppressed patients not receiving antimicrobial prophylaxis. Performing bronchoalveolar lavage may improve the rate of aetiological diagnosis, leading to a change in therapeutic management and improved outcomes. The optimal length of antibiotic therapy for bacterial HAP/VAP has not been well defined, but it should perhaps be longer than in the general population. Mortality associated with HAP/VAP is high.
HAP/VAP in transplant patients is frequent and is associated with increased mortality. There is room for improvement in gaining knowledge about the management of HAP/VAP in this population.
Utility of fiber-optic bronchoscopy in pulmonary infections among abdominal solid-organ transplant patients: A comprehensive review
2019, Respiratory Medicine
Citation Excerpt :
However, the relative risk of pneumonia was noted to be lower within 6–12 months versus after 6–12 months of renal transplantation [2.97 (95% confidence interval [CI], 1.13–7.28) and 3.62 (95% CI, 1.22–9.84)] in a study by Chang et al. The same study showed that bacterial (21 of 92 patients) and mixed-bacterial (10 of 92 patients) infections were the most common etiologies of pneumonia with Staphylococcus aureus, Streptococcus pneumonia, and gram-negative bacilli as the leading microbes, respectively [1]. Several studies have documented the utility of FOB in diagnosis of bacterial pneumonia among aSOT patients.
Pulmonary infections are frequent complications in abdominal solid-organ transplantation (aSOT) which may threaten patient and allograft survival. Accurate diagnosis and treatment of pulmonary infections in this population can be challenging. Immunosuppressive therapy not only increases the risk of acquiring opportunistic and non-opportunistic infections, but it also impairs the inflammatory responses associated with microbial invasion which in an otherwise normal host produce clinical and radiologic responses that allow for early identification of the offending pathogen. Serologic testing is not a reliable diagnostic modality. Direct microbiological sampling is often necessary to make a definitive diagnosis early in the clinical course to optimize timely, targeted therapy while reducing the risk of developing antimicrobial resistance, and minimize adverse effects of therapy, if any. Fiber-optic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) or transbronchial lung biopsy (TBB) offers such diagnostic advantage and possesses a potential therapeutic value too. This comprehensive review discusses the potential benefits of FOB alongside its risks and complications, indications and contraindications, and techniques. Additionally, the essay highlights FOB's utility and yield specifically with regard to type and timing of infections in aSOT patients.
Infectious Complications Following Solid Organ Transplantation
2019, Critical Care Clinics
Citation Excerpt :
Perioperative antibiotics, which are focused on preoperative cultures from the recipient and donor, reduce the incidence of early bacterial pneumonia to less than 10%.20,21 Regarding cardiac, hepatic, and renal transplants, the incidence of early bacterial pneumonia is 15%, 9%, and 4% to 6%, respectively,18–20,26,27 with a mortality of 21% to 35% in liver and kidney transplant recipients. However, mortality between nosocomial and community-acquired infection was extreme at 58% compared with 8%20–22 with mechanical ventilation and nosocomial infections at a higher increased risk for death.18,20–22,24
Diagnostic protocol for acute febrile syndrome in the transplanted patient. Empirical treatment
2018, Medicine (Spain)
La fiebre es una manifestación frecuente en los receptores de trasplantes de órgano sólido (TOS) y precursores hematopoyéticos (TPH). Durante las primeras semanas predominan las infecciones nosocomiales como la infección por C. difficile, las complicaciones infecciosas de la cirugía y la infección derivada del donante (en TOS). La neutropenia inicial determina el riesgo de infección en TPH. Después del primer mes suelen aparecer infecciones relacionadas con la inmunodepresión celular como aspergilosis pulmonar, infección por CMV, neumonía por P. jirovecii, tuberculosis, etc. En caso de presentar infiltrado pulmonar se debe plantear la realización de broncoscopia. Pueden ser necesarias técnicas moleculares o la detección de antígenos (PCR de CMV, antígeno criptocócico, etc.) y la biopsia del injerto o de órganos afectos (neumonitis por CMV, rechazo del injerto, recidiva de la enfermedad de base). Para iniciar el tratamiento empírico de la fiebre es esencial conocer el tipo de trasplante, momento de la fiebre, adquisición nosocomial y órganos afectados.
Fever is a common manifestation in recipients of solid organ transplantation (SOT) and stem cell transplantation (SCT). During the first weeks, nosocomial infections predominate such as C. difficile, the infectious complications of surgery and donor-derived infection (in SOT). Initial neutropenia determines the risk of infection in SCT. Infections related to cellular immunosuppression such as pulmonary aspergillosis, CMV infection, P. jirovecii pneumonia, tuberculosis, etc., usually appear after the first month. Bronchoscopy should be considered if there is pulmonary infiltration. Molecular techniques or antigen detection might be necessary (PCR of CMV, cryptococcal antigen, etc.) and biopsy of the graft or affected organs (CMV pneumonitis, graft rejection, recurrence of baseline disease). It is essential to establish the type of transplant, time of fever onset, nosocomial acquisition and organs affected in order to start empirical treatment of the fever.
Bacteria Isolated from Respiratory Tract Specimens of Renal Recipients with Acute Respiratory Distress Syndrome Due to Pneumonia: Epidemiology and Susceptibility of the Strains
2015, Transplantation Proceedings
We estimated species distribution and frequency of antimicrobial resistance among bacterial pathogens isolated from respiratory tract specimens of renal recipients with acute respiratory distress syndrome (ARDS) due to pneumonia.
We retrospectively collected patient demographics and clinical characteristics and microbiologic culture data with the use of standard microbiologic procedures and commercially available tests.
From January 2001 to August 2014, 320 respiratory tract specimens were obtained from 94 renal recipients with ARDS. Bacterial cultures were positive in 134 specimens from 68 recipients (72.3%), yielding 139 bacterial strains. The most commonly isolated species were gram-negative bacteria (111 isolates) with dominance of Acinetobacter baumanii (29.7%) and Pseudomonas aeruginosa (18.0%). The gram-negative bacteria were relatively resistant to 1st- and 2nd-generation cephalosporin and monocyclic beta-lactam and relatively sensitive to levofloxacin and meropenem, with rates of resistance of 80.2%, 76.6%, 73.9%, 36.0%, and 44.1%, respectively. The gram-positive bacteria, excluding Streptococcus uberis, were sensitive to glycopeptides and oxazolidone.
Gram-negative bacteria predominated as 79.9% of isolates from respiratory tract specimens of renal recipients with ARDS. The gram-negative bacteria were relatively sensitive to levofloxacin and meropenem and the gram-positive bacteria were sensitive to glycopeptides and oxazolidone.

View all citing articles on Scopus

View full text

Chest

Clinical InvestigationsPNEUMONIAThe Diagnosis of Pneumonia in Renal Transplant Recipients Using Invasive and Noninvasive Procedures

Study objectives

Subjects and methods

Results

Conclusion

Section snippets

Patients

Results

Discussion

ACKNOWLEDGMENT

Chest

Med Clin North Am

Chest

Am J Med

Infect Dis Clin North Am

Am J Med

Chest

Blood

Kidney Int

Lancet

Strategies to improve long-term outcomes after renal transplantation

N Engl J Med

The lung in the immunocompromised patient: infectious complications; part 1

Respiration

The lung in the immunocompromised patient: infectious complications; part 2

Respiration

Quantitative cultures of endotracheal aspirates for the diagnosis of ventilator-associated pneumonia

Am Rev Respir Dis

The utility of open lung biopsy in patients with hematologic malignancies

Am J Respir Crit Care Med

Open-lung biopsy in the renal transplant recipient

Surgery

Diagnosis of pneumonitis in immunocompromised patients by open lung biopsy

Cancer

Use of bronchoscopy in the diagnosis of infection in the immunocompromised host

Thorax

Bronchoalveolar lavage for diagnosing acute bacterial pneumonia

J Infect Dis

Clinical Investigations
PNEUMONIA
The Diagnosis of Pneumonia in Renal Transplant Recipients Using Invasive and Noninvasive Procedures