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Hypercalcaemia as an early warning sign for Pneumocystis pneumonia among renal transplant recipients

April 10 2018

Without TMP-SMX prophylaxis, around 5-15% of renal transplant recipients will develop Pneumocystis jirovecii pneumonia (PJP), with a mortality rate of 13-38%. However, practices vary between centres. The Kidney Disease: Improving Global Outcomes guidelines recommend 3-6 months prophylaxis transplant and a further 1.5 months during rejection. The European Renal Best Practice guidelines recommend 4 months post-transplant and a further 3-4 months during rejection.

Dr Jonathan Ling and colleagues in Australia recently presented a case series of four patients who presented several years post-transplant with worsening exertional dyspnea, bilateral fine crackles upon auscultation, and a CT scan showing ground-glass opacities, but without fever. Treatment with TMP-SMX corrected calcium levels and resolved the dyspnea. All patients had initially received prophylaxis but

In this case an outpatient waiting area was identified as the source of transmission. Outbreak management was implemented which included universal 12-month prophylaxis, N95 masks for patient with respiratory symptoms, and fast-tracking of sputum samples through pathology.

 What can I do?

  • If a patient presents with exertional dyspnea several years after a renal transplant, test their serum calcium.
  • Check for the following PJP risk factors in their history: recurrent rejection, renal failure, glucocorticoid use and CMV infection.
  • If positive, test for PJP (e.g. PCR test on BAL fluid and/or sputum) before treating with immunosuppressive drugs such as prednisolone.

 

Read the full paper: Ling et al (2017) Hypercalcaemia preceding diagnosis of Pneumocystis jirovecii pneumonia in renal transplant recipients. Clinical Kidney Journal 10(6):845–851