Clinical characteristics and comorbidities in patients with pulmonary cryptococcosis
There were 42 patients with early CKD and 14 patients with advance CKD. Compared with the group with early CKD, the group with advance CKD had similar age, sex, and body mass index; tended to have higher number of patients with pathogenic diagnosis; had significantly higher rate of disseminated pulmonary cryptococcosis; similar comorbidities of pulmonary diseases, diabetes mellitus, connective tissue diseases, and malignancy; and more frequently used immunosuppressive drugs. In the present study, only 1 patient in the early CKD group was on hemodialysis (Table 1).
Comparison of symptoms and laboratory findings in patients with pulmonary cryptococcosis
Compared with the group with early CKD, the group with advance CKD had similar percentage of asymptomatic patients; similar pulmonary cryptococcosis-related symptoms of cough, sputum, chest pain, and dyspnea; significantly higher percentage of patients who have fever (>37.5 °C) (57.1% vs. 19.0%, p <0.01); and on laboratory data, significantly higher white blood cell count (8550/ml vs 6150/ml, p = 0.01) and CRP level (2.1 mg/dl vs 0.2 mg/dl, p = 0.02) but significantly lower serum albumin (3.0 g/dl vs 3.8 g/dl, p <0.01) and similar lymphocyte count, serum calcium, immunoglobulin G, and anticryptococcal antigen (Table 2).
Comparison of the radiologic findings on HRCT in patients with pulmonary cryptococcosis
According to previous reports on the different distribution and patterns of radiologic findings in pulmonary cryptococcosis, depending on immune status (12, 23), we evaluated and compared the area and features of pulmonary abnormalities between patients with early CKD and those with advance CKD. Compared with the group with early CKD, the group with advance CKD had lower number of patients whose pulmonary abnormalities were limited to 1 lobe (28.6% vs 57.1%, p = 0.06) and were distributed in only a unilateral lung field (50.0% vs 76.2%, p = 0.07); similar patterns of single nodule, multiple nodules, masses, cavitation, consolidation, and ground glass attenuation; and significantly higher number of patients with pleural effusion (21.4% vs 2.4%, p = 0.03) (Table 3).
Treatment and outcome of patients with pulmonary cryptococcosis
The number of patients who took antifungal drugs and the duration of antifungal drug treatment were not different between the 2 groups. Azole was the antifungal drug used by 94.1% of patients with early CKD and 75.0% of patients with advance CKD. 25 % of patients with advance CKD were treated by amphotericin B because of dissemination or co-infection with aspergillus. Surgery tended to be performed more frequently for patients with early CKD than for those with advance CKD (12.8% vs 0%, p = 0.09). Evaluation of the clinical outcomes of 40 patients with early CKD and 11 patients with advance CKD showed that the rate of recovery after treatment was significantly higher in patients with early CKD than in those with advance CKD (92.5% vs. 63.6%, p = 0.02) (Table 4). About the disposition of patients who did not recover, 2 patients were died and 1 patient were exacerbated by fluconazole and recovered after alternation to voriconazole in patients with early CKD. In patients with advance CKD, all of 4 patients were died.
Multivariate analysis of the clinical impact of CKD on pulmonary cryptococcosis Previous studies reported that immunocompromising comorbidities, such as diabetes mellitus, malignancy, and immunosuppressive drug use, were associated with clinical characteristics (5, 11, 12). The current study found that immunosuppressive drug was used more often by patients with advance CKD than by those with early CKD (Table 1). Because this might affect the current results, we performed multivariate analysis for the variables which were significantly different between patients with early CKD and those with advance CKD including fever, white blood cell count, serum albumin and CRP in the model with eGFR <45 or not and immunosuppressive drug use or not. Disseminated cryptococcosis, pleural effusion, and recovery after treatment were not assessed because of the small sample size. On multivariate analysis, fever, white blood cell count, serum albumin, and CRP remained significantly different between patients with early CKD and those with advance CKD, even after adjustment by immunosuppressive drug use or not (Table 5).