title: Immunosuppressant dose reduction and long-term rejection risk in renal transplant recipients with severe bacterial pneumonia.
abstract: BACKGROUND
  Due to lifelong immunosuppression, renal transplant recipients (RTRs) are at risk of infectious complications such as pneumonia. Severe pneumonia results in respiratory failure and is life‑threatening. We aimed to examine the influence of immunosuppressant dose reduction on RTRs with bacterial pneumonia and respiratory failure.
  
  
  METHODS
  From January 2001 to January 2011, 33 of 1,146 RTRs at a single centre developed bacterial pneumonia with respiratory failure. All patients were treated using mechanical ventilation and aggressive therapies in the intensive care unit.
  
  
  RESULTS
  Average time from kidney transplantation to pneumonia with respiratory failure was 6.8 years. In-hospital mortality rate was 45.5% despite intensive care and aggressive therapies. Logistic regression analysis indicated that a high serum creatinine level at the time of admission to the intensive care unit (odds ratio 1.77 per mg/dL, 95% confidence interval 1.01-3.09; p = 0.045) was a mortality determinant. Out of the 33 patients, immunosuppressive agents were reduced in 17 (51.5%). We found that although immunosuppressant dose reduction tended to improve in-hospital mortality, this was not statistically significant. Nevertheless, during a mean follow-up period of two years, none of the survivors (n = 18) developed acute rejection or allograft necrosis.
  
  
  CONCLUSIONS
  In RTRs with bacterial pneumonia and respiratory failure, higher serum creatinine levels were a mortality determinant. Although temporary immunosuppressant dose reduction might not reduce mortality, it was associated with a minimal risk of acute rejection during the two-year follow-up. Our results suggest that early immunosuppressant reduction in RTRs with severe pneumonia of indeterminate microbiology may be safe even when pathogens are bacterial in nature.
authors.forename: Chia-Jen
authors.initials: CJ
authors.lastname: Shih
authors.forename: Der-Cherng
authors.initials: DC
authors.lastname: Tarng
authors.forename: Wu-Chang
authors.initials: WC
authors.lastname: Yang
authors.affiliation: Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei 11217, Taiwan. cyyang3@vghtpe.gov.tw.
authors.forename: Chih-Yu
authors.initials: CY
authors.lastname: Yang
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001424:Bacterial Infections / Q000150:complications*; D015897:Comorbidity; D003404:Creatinine / Q000097:blood; D005260:Female; D006084:Graft Rejection; D017052:Hospital Mortality; D006801:Humans; D007165:Immunosuppression Therapy / Q000009:adverse effects; D007166:Immunosuppressive Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D007362:Intensive Care Units; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011014:Pneumonia / Q000150:complications* / Q000382:microbiology; D051437:Renal Insufficiency / Q000150:complications* / Q000276:immunology / Q000601:surgery*; D012131:Respiratory Insufficiency / Q000150:complications; D012189:Retrospective Studies; D012307:Risk Factors
chemical_list: D000900:Anti-Bacterial Agents; D007166:Immunosuppressive Agents; D003404:Creatinine
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