Epidemiology and risk factors for cytomegalovirus infection in glomerular diseases treated with immunosuppressive therapy.

AIM: Cytomegalovirus (CMV) infections are associated with morbidity and mortality. We aimed to describe the epidemiology, risk factors and outcomes of CMV infection among patients with glomerulonephritis (GN) who received potent immunosuppressants (IS). METHODS: Single-centre retrospective study of adults with biopsy-proven GN prescribed methylprednisolone (MP), cyclophosphamide (CYC) or rituximab (RTX). Primary endpoint was CMV infection defined by significant CMV antigenaemia (>10 positive cells in 106 cells) or viraemia (>2000 copies/mL). Death was related to CMV if CMV infection occurred within the same hospitalization as death. RESULTS: Ninety-four patients were studied. CYC was prescribed in 65% and MP in 71% of the cohort. Only two patients received RTX and 15 patients received plasma exchanges (PEX). Median follow up was 31.9 (IQR: 13.7, 53.6) months. CMV infection occurred in 13 patients (13.8%) at 1.3 (0.6, 3.0) months from biopsy. Patients with CMV infection had higher serum creatinine [404 (272, 619) vs. 159 (93, 317) µmol/L, P < 0.001] and greater proteinuria [UPCR 7.5, (4.8, 11.8) vs. 4.2 (2.3, 8.4) g/g, P = 0.02] than those who did not have CMV infection. Also, more patients received CYC (92% vs. 60%, P = 0.03), RTX (15% vs. 0, P = 0.02) and PEX (38% vs. 12%, P = 0.01) than those who did not have CMV infection. Two patients had CMV-related deaths. CONCLUSION: Cytomegalovirus infection is common in GN patients receiving potent IS. Surveillance and possibly anti-viral prophylaxis should be considered for high-risk patients.

Severe infections in patients with lupus nephritis treated with immunosuppressants: A retrospective cohort study.

AIM: Lupus nephritis (LN) is associated with significant morbidity and mortality and hence usually treated aggressively with immunosuppressants. This predisposes LN patients to increased infections, yet few studies have evaluated LN patients for infective complications. We aimed to describe the epidemiology and identify risk factors for infections requiring hospitalization among patients with biopsy-proven LN. METHODS: This was a single-centre retrospective cohort study of patients with biopsy-proven LN between 1 January 2000 and 31 May 2009. Patients were excluded if they were <16 years old at time of biopsy, had previous kidney transplant or if pharmacotherapy data were incomplete. Hospitalizations for infections, bacteraemia and polymicrobial infections were recorded until patients' last visit or when they received immunosuppression for non-glomerulonephritis indications, such as solid organ transplant or chemotherapy. RESULTS: We studied 189 patients who had biopsy-proven lupus nephritis. Median age at diagnosis was 36.9 (IQR: 27.4, 47.5) years and 82% were female. Most patients received at least one immunosuppressant after LN diagnosis, including glucocorticosteroids in 94.2%. One hundred and four patients (60.3%) had at least one hospitalization for infection at 11 (1, 53) months from diagnosis. Bacteraemia occurred in 26 patients (13.8%) and 32 patients (16.9%) had polymicrobial infections. On multivariate analysis, LN relapse was associated with hospitalization for infection (OR 2.33 (1.18, 4.60), P = 0.01) and bacteraemia (OR 3.47 (1.05, 11.45), P = 0.04). Infection-related mortality occurred in 10 patients (5.3%). CONCLUSION: Serious infections are common among patients with LN and are associated with mortality.

Synergistic impact of pre-diabetes and immunosuppressants on the risk of diabetes mellitus during treatment of glomerulonephritis and renal vasculitis.

BACKGROUND: Glomerulonephritis is often treated with kidney-saving, but potentially diabetogenic immunosuppressants such as glucocorticosteroids and calcineurin inhibitors. Unfortunately, there are little data on dysglycemia before and after diagnosis and during treatment of glomerulonephritis. We aimed to evaluate the occurrence and risk factors for pre-diabetes and incident diabetes among non-diabetic patients with glomerular disease with or without treatment with immunosuppressants. METHODS: A single-center, retrospective cohort study was performed on 229 non-diabetic immunosuppressantnaïve adults diagnosed with glomerulonephritis and renal vasculitis. Patients with known diabetes and prior immunosuppressant treatment were excluded. Outcomes of new-onset pre-diabetes and new-onset diabetes were defined according to American Diabetic Association criteria. RESULTS: Pre-diabetes was present pre-biopsy in 74 of the 229 patients (32.3%). During the median follow-up of 34.0 (23.3-47.5) months, 29 patients (12.7%) developed new-onset diabetes and 58 (25.3%) had new-onset prediabetes. Immunosuppressive therapy in patients with pre-existing pre-diabetes was associated with increased odds of new-onset diabetes compared to those without either risk factor (26.0% versus 5.0%; odds ratio, 6.67; 95% confidence interval [CI], 1.41 to 31.64), P = 0.02). CONCLUSION: New-onset diabetes after immunosuppressant treatment occurred in one-quarter of patients with glomerulonephritis and pre-existing pre-diabetes. Physicians should screen for pre-diabetes when planning treatment with immunosuppressants, as its presence significantly increases the risk of diabetes mellitus.