title: Underlying renal insufficiency: the pivotal risk factor for Pneumocystis jirovecii pneumonia in immunosuppressed patients with non-transplant glomerular disease.
abstract: OBJECTIVE
  Data on PCP in patients with glomerular disease are rare. The aim of this study was to assess the predictors of PCP development, the risk factors for mortality and the incidence of acute kidney injury (AKI) when high-dose trimethoprim-sulphamethoxazole (TMP-SMX) was used in patients with non-transplant glomerular disease.
  
  
  METHODS
  Forty-seven patients with PCP, as confirmed by positive results for Pneumocystis jirovecii DNA or Pneumocystis jirovecii cysts tested by a methenamine silver stain between January 1, 2003, and December 30, 2012, were retrospectively investigated. The baseline characteristics of glomerular disease, clinical findings of PCP and renal parameters after treatment were collected. Predictors for PCP development and risk factors for mortality were determined using a multivariate logistic regression analysis.
  
  
  RESULTS
  All PCP patients exclusively received immunosuppressants. Baseline renal insufficiency [estimated glomerular filtration rate (eGFR) <60 mL/min·1.73 m2] was present in 87.23 % of patients. The overall mortality rate was 29.79 %. A pulmonary coinfection and the need for mechanical ventilation were independently associated with PCP mortality. A lower eGFR, lower serum albumin level and a higher percentage of global glomerulosclerosis were independent predictors of PCP in patients with IgA nephropathy receiving immunosuppressants. AKI occurred in 60.47 % of patients who received TMP-SMX. After treatment cessation, 93.75 % of surviving patients showed a recovery of renal function to baseline values.
  
  
  CONCLUSIONS
  PCP is a fatal complication in patients with glomerular disease, and the use of immunosuppressants may be a basic risk factor for this infection. Underlying renal insufficiency and high renal pathology chronicity are the key risk factors for PCP in IgA nephropathy. TMP-SMX therapy remains an ideal choice because of high treatment response and frequently reversible kidney injury.
authors.affiliation: Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
authors.forename: Wen-Ling
authors.initials: WL
authors.lastname: Ye
authors.affiliation: Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
authors.forename: Nan
authors.initials: N
authors.lastname: Tang
authors.affiliation: Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
authors.forename: Yu-Bing
authors.initials: YB
authors.lastname: Wen
authors.affiliation: Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
authors.forename: Hang
authors.initials: H
authors.lastname: Li
authors.affiliation: Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
authors.forename: Min-Xi
authors.initials: MX
authors.lastname: Li
authors.affiliation: Intensive Care Unit, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
authors.forename: Bin
authors.initials: B
authors.lastname: Du
authors.affiliation: Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China. lixmpumch@126.com.
authors.forename: Xue-Mei
authors.initials: XM
authors.lastname: Li
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced / Q000453:epidemiology*; D000328:Adult; D000368:Aged; D060085:Coinfection / Q000401:mortality; D005260:Female; D005919:Glomerular Filtration Rate; D005922:Glomerulonephritis, IGA / Q000150:complications / Q000188:drug therapy; D005923:Glomerulosclerosis, Focal Segmental / Q000209:etiology; D006801:Humans; D016867:Immunocompromised Host; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D015994:Incidence; D008297:Male; D008875:Middle Aged; D045363:Pneumocystis carinii; D011020:Pneumonia, Pneumocystis / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy; D051436:Renal Insufficiency, Chronic / Q000453:epidemiology* / Q000209:etiology / Q000503:physiopathology; D012121:Respiration, Artificial; D012189:Retrospective Studies; D012307:Risk Factors; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000009:adverse effects*; D055815:Young Adult
chemical_list: D007166:Immunosuppressive Agents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination
keywords: Acute kidney injury; Chronic renal insufficiency; Glomerular disease; Immunosuppressants; Pneumocystis jirovecii pneumonia; Trimethoprim–sulphamethoxazole