Severe Infectious Complications in Kidney Transplant Recipients in the Intensive Care Unit

Abstract

Kidney transplantation is the most frequent solid organ transplantation. Thanks to the advances in immunosuppressive therapy and the development of new immunosuppressive drugs, eligibility criteria of donors and recipients have expanded, incidence of acute rejection has decreased, and long-term graft survival has improved. However, despite a better management of antimicrobial prophylaxis, transplantation of patients with more comorbid conditions and use of more potent immunosuppressive regimens have led to an increase in the incidence of infectious complications. They represent the first reason for admission to the intensive care unit (ICU) among kidney transplant recipients. In 20–30% of cases, ICU admission is preceded by the treatment of an acute rejection. Moreover, the reactivation of cytomegalovirus, which could promote the occurrence of infections by its immunomodulatory properties, is found before or during ICU admission in 16–36% patients. Infected sites and pathogens depend on the time between transplantation and ICU admission, but especially on the severity of immune depression. Pneumonia, which is bacterial in two-third of cases, is the leading cause. Pneumocystis jirovecii is the most frequent opportunistic pathogen. In-hospital mortality range between 20 and 60%. Chronic allograft dysfunction is observed in 40% of survivors. Therefore, intensivists should be aware of epidemiology, risk factors, clinical presentation, and treatment of the main infectious complications following kidney transplantation.