title: Predictors of immune reconstitution syndrome in organ transplant recipients with cryptococcosis: implications for the management of immunosuppression.
abstract: Risk factors including how changes in immunosuppression influence the occurrence of immune reconstitution syndrome (IRS) in solid organ transplant (SOT) recipients with cryptococcosis have not been fully defined.
  
  
  
  SOT recipients with cryptococcosis were identified and followed for 12 months. IRS was defined based on previously proposed criteria.
  
  
  
  Of 89 SOT recipients, 13 (14%) developed IRS. Central nervous system (CNS) disease (adjusted odds ratio [AOR], 6.23; P = .03) and discontinuation of calcineurin inhibitor (AOR, 5.11; P = .02) were independently associated with IRS. Only 2.6% (1/13) of the patients without these risk factors developed IRS compared with 18.8% (6/32) with 1 risk factor, and 50% (6/12) with both risk factors (χ(2) for trend, P = .0001). Among patients with CNS disease, those with neuroimaging abnormalities (P = .03) were more likely to develop IRS, irrespective of serum or CSF cryptococcal antigen titers and fungemia. Graft rejection after cryptococcosis was observed in 15.4% (2/13) of the patients with IRS compared with 2.6% (2/76) of those without IRS (P = .07).
  
  
  
  We determined variables that pose a risk for IRS and have shown that discontinuation of calcineurin inhibitors was independently associated with 5-fold increased risk of IRS in transplant recipients with cryptococcosis.
authors.affiliation: Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei.
authors.forename: Hsin-Yun
authors.initials: HY
authors.lastname: Sun
authors.affiliation: Duke University Medical Center, Durham, North Carolina.
authors.forename: Barbara D
authors.initials: BD
authors.lastname: Alexander
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: Shirish
authors.initials: S
authors.lastname: Huprikar
authors.affiliation: University of Maryland School of Medicine, Baltimore.
authors.forename: Graeme N
authors.initials: GN
authors.lastname: Forrest
authors.affiliation: Department of Internal Medicine, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina.
authors.forename: Didier
authors.initials: D
authors.lastname: Bruno
authors.affiliation: Department of Medicine, Emory University, Atlanta, Georgia.
authors.forename: G Marshall
authors.initials: GM
authors.lastname: Lyon
authors.affiliation: Medical University of South Carolina, Charleston.
authors.forename: Dannah
authors.initials: D
authors.lastname: Wray
authors.affiliation: St John Medical Center, Detroit, Michigan.
authors.forename: Leonard B
authors.initials: LB
authors.lastname: Johnson
authors.affiliation: Department of Medicine, University of Virginia, Charlottesville.
authors.forename: Costi D
authors.initials: CD
authors.lastname: Sifri
authors.affiliation: Department of Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Raymund R
authors.initials: RR
authors.lastname: Razonable
authors.affiliation: Miller School of Medicine, University of Miami, Florida.
authors.forename: Michele I
authors.initials: MI
authors.lastname: Morris
authors.affiliation: Department of Medicine, Northwestern University, Chicago, Illinois.
authors.forename: Valentina
authors.initials: V
authors.lastname: Stosor
authors.affiliation: Department of Medicine, University of Pittsburgh, Pennsylvania.
authors.forename: Marilyn M
authors.initials: MM
authors.lastname: Wagener
authors.affiliation: Department of Medicine, University of Pittsburgh, Pennsylvania.
authors.forename: Nina
authors.initials: N
authors.lastname: Singh
mesh_terms: D000368:Aged; D065095:Calcineurin Inhibitors / Q000008:administration & dosage; D003453:Cryptococcosis / Q000150:complications*; D005260:Female; D006801:Humans; D054019:Immune Reconstitution Inflammatory Syndrome / Q000453:epidemiology*; D007165:Immunosuppression Therapy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D016377:Organ Transplantation / Q000009:adverse effects*; D015995:Prevalence; D012307:Risk Factors; D066027:Transplant Recipients
chemical_list: D065095:Calcineurin Inhibitors
keywords: Cryptococcus; fungal infections; immunosuppression; transplant