Recipients of solid organ transplants have 24-40% incidence of opportunistic fungal infections with a very high mortality of 70-100%. This is related to the balance of environmental exposure and net state of immunosuppression. We had studied the records of 850 patients who had undergone renal transplantation at our Institute during Jan-1977 to Dec-2001. The immunosuppression protocol included conventional therapy with azathioprine and prednisolone in 105 (12%), triple-drug therapy including cyclosporine in 621 (73%) and only cyclosporine and azathioprine in 124 (15.%) patients. The treatment of acute rejection consisted of intravenous.methylprednisolone and use of monoclonal antibodies when required.
The analysis showed occurrence of opportunistic fungal infections in 83 patients (9.8%) including candidiasis in 25 (2.8%), cryptococcosis in 16 (1.9%), aspergillosis in 20 (2.3%), mucormycosis 17 (2.0%) and rare fungal infections in 5 others including pheohyphomycosis in 3 and disseminated histoplasmosis in 2 patients. This analysis compared with earlier studies from our centre, showed a three-fold rise in incidence of angio-invasive infections including aspergillosis and mucormycosis after the addition of cyclosporine and other potent drugs in the immunosuppressive regimen. The ante-mortum diagnosis was made only in 36% of such cases compared with 73% in case of Candida and Cryptococcal infections. Overall mortalty was thus higher in these patients, mucormycosis (89%) and aspergillosis (70%) as compared with non-invasive fungi like candidiasis (40%) and cryptococcosis (50%). We also analysed the autopsy findings in 79 patients and documented higher incidence of angioinvasive fungal infections including aspergillosis in 11 (14%) and mucormycosis 10 (13%) compared with the relative low incidence for disseminated candidiasis seen in 5 (6%) and cryptococcosis seen in 4 (5%) patients. Histoplasmosis was uncommon in our patients. The underling pre-disposing conditions in autopsied cases inluded CMV disease (35%), chronic allograft dysfunction (19%), leukopenia and hepatitis (16%) and diabetes (13%).
Systemic infections are an important cause of morbidity and mortality in renal transplant recipients. Whereas candidiasis and cryptococcosis are common and can be effectively treated, there has been a recent rise in angio-invasive fungal infections such as aspergillosis and mucormycosis which are associated with a high mortality. A high incidence of CMV infections accompanies invasive fungal infections. Concomitant bacterial infections often complicate picture. Timely detection of the serious fungal infections and institution of therapy are important in reducing the mortality.