Secular Trends in Infection-Related Mortality after Kidney Transplantation

Abstract

Background and objectives: Infections are the most common noncardiovascular causes of death after kidney transplantation. We analyzed the current infection-related mortality among kidney transplant recipients in a nationwide cohort in Finland.

Design, setting, participants, & measurements: Altogether, 3249 adult recipients of a first kidney transplant from 1990 to 2012 were included. Infectious causes of death were analyzed, and the mortality rates for infections were compared between two eras (1990-1999 and 2000-2012). Risk factors for infectious deaths were analyzed with Cox regression and competing risk analyses.

Results: Altogether, 953 patients (29%) died during the follow-up, with 204 infection-related deaths. Mortality rate (per 1000 patient-years) due to infections was lower in the more recent cohort (4.6; 95% confidence interval, 3.5 to 6.1) compared with the older cohort (9.1; 95% confidence interval, 7.6 to 10.7); the incidence rate ratio of infectious mortality was 0.51 (95% confidence interval, 0.30 to 0.68). The main causes of infectious deaths were common bacterial infections: septicemia in 38% and pulmonary infections in 45%. Viral and fungal infections caused only 2% and 3% of infectious deaths, respectively (such as individual patients with Cytomegalovirus pneumonia, Herpes simplex virus meningoencephalitis, Varicella zoster virus encephalitis, and Pneumocystis jirovecii infection). Similarly, opportunistic bacterial infections rarely caused death; only one death was caused by Listeria monocytogenes, and two were caused by Mycobacterium tuberculosis. Only 23 (11%) of infection-related deaths occurred during the first post-transplant year. Older recipient age, higher plasma creatinine concentration at the end of the first post-transplant year, diabetes as a cause of ESKD, longer pretransplant dialysis duration, acute rejection, low albumin level, and earlier era of transplantation were associated with increased risk of infectious death in multivariable analysis.

Conclusions: The risk of death due to infectious causes after kidney transplantation in Finland dropped by one half since the 1990s. Common bacterial infections remained the most frequent cause of infection-related mortality, whereas opportunistic viral, fungal, or unconventional bacterial infections rarely caused deaths after kidney transplantation.

Keywords: Albumins; Bacterial Infections; Cause of Death; Encephalitis; Finland; Follow-Up Studies; Fungal Viruses; Herpesvirus 3, Human; Incidence; Kidney Failure, Chronic; Listeria monocytogenes; Meningoencephalitis; Mycobacterium tuberculosis; Mycoses; Pneumocystis carinii; Pneumonia; Sepsis; Simplexvirus; creatinine; cytomegalovirus; diabetes mellitus; infections; kidney transplantation; mortality risk; risk factors.

Graphical abstract

Figure 1.

Cumulative probability of infectious death was lower in patients transplanted between 2000–2012 compared to 1990–1999. Continuous line: years 1990–1999; dotted line: years 2000–2012.