Blog entry by Meguid El Nahas
A review article by McCaughan and Courtney in NDT January 2012 reviews the situation relating to the apparaent increased incidence of PJP recipients of renal allografts. A number of recent reproted outbreaks in renal transplant recipients have raised concern about adequacy of prophylaxis strategies. In general it is considered that PJP prophylaxis is justified and should be considered if the risk of disease is estimated to exceed 3%. The incidence of PJP infections in moderately immunosuppressed renal transplant recipients is usually <1%. Six renal centres reporting outbraks in Asia and Europe have all adopted the surveillance rather than prophylaxis approach based on the above assumptions. However, it is important toi appreciate that the risk is higher in:
1. High risk patients
2. Higher immunosuppression including use of ATG
3. Frequent rejection episodes
4. CMV infections
Currernt guidelines recommend 3-6 month prophylaxis with septrin (trimethoprim-sulfamethoxazole) from the time of transplantation. These guidelines may warrant review as most recent outbreaks took place more than 6 months after transplantation.
Therefore in higher risk and susceptibe individuals, it would be advisable to continue prophylaxis until the immunosuppression burden can be reduced.
Routine prophylaxis for all may be justifiable.
Prolonged immunosuppression may also be justifiable specially in the days of ever more agressive immunosupressive therapies.
Nephrologists need to inform their decision based on:
What is the justification of the Intervention?
Who is most susceptible to PJP and warrants prophylaxis?
Risk: benefit analysis; Septrin is not without its risks and side effects and PJP can be fatal!
Cost: benefit analysis.
JA, AE. Pneumocystis jiroveci pneumonia in renal transplantation: time to review our practice? Nephrol Dial Transplant. 2012 Jan;27(1):13-5. Epub 2011 Aug 3.