Epidemiology and Outcomes of Extrapulmonary Invasive Fungal Infections After Kidney Transplantation in Northern India.

BACKGROUND

Extrapulmonary invasive fungal infections (IFIs) in kidney transplant recipients (KTRs) are understudied, particularly in endemic, resource-limited settings. This study evaluated the epidemiology, risk factors, and outcomes of extrapulmonary IFIs in KTRs in northern India.

METHODS

In this nested case-control study of 1649 KTRs (2007-2022), microbiologically proven extrapulmonary IFI cases were identified from microbiology and histopathology databases.

RESULTS

Extrapulmonary IFI occurred in 67 KTRs (4.1%). Cryptococcosis (46.3%) and candidiasis (20.9%) were the predominant infections. The central nervous system was the most common site (44.8%), followed by the bloodstream (22.4%). The mean age was 46.78 years, and 85.1% were males. The median time to infection was 55 months posttransplant, and 79.1% of infections occurred beyond 1 year posttransplant. Median estimated glomerular filtration rate (eGFR) was 43 mL/min/1.73 m2, and acute graft dysfunction was present in 49.3% cases. Comorbidities included diabetes (44.8%), chronic renal allograft injury (59.7%), acute rejection (38.8%), bacterial infection (26.9%), and cytomegalovirus disease (13.4%). Diabetes (OR 2.27, p = 0.038) and methylprednisolone pulses for rejection (OR 3.19, p = 0.025) were independently associated with IFI. Infection-related mortality was 35.8%; disseminated infection (HR 3.72, p = 0.020) and requirement for kidney replacement therapy (KRT) (HR 3.98, p = 0.011) independently predicted death. Note that, 5- and 10-year patient survival was significantly lower in cases than in controls (74.1% and 48.3% vs. 92.3% and 74.9%; p = 0.008), whereas death-censored graft survival was comparable.

CONCLUSIONS

Extrapulmonary IFIs are late-onset and commonly present as cryptococcal meningitis or candidemia. Diabetes and methylprednisolone pulses increase infection risk, while dissemination and KRT requirement predict mortality.