Clinical characteristics and comorbidities in patients with pulmonary cryptococcosis
There were 42 patients with early CKD and 14 patients with advanced CKD. Compared with the group with early CKD, the group with advanced 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 frequent use of 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 advanced 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 had 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 the immune status (12, 23), we evaluated and compared the area and features of pulmonary abnormalities between patients with early CKD and those with advanced CKD. Compared with the group with early CKD, the group with advanced 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 advanced CKD. In 25% of patients with advanced CKD, amphotericin B was administered for dissemination or coinfection with aspergillus. Surgery tended to be performed more frequently for patients with early CKD than for those with advanced CKD (12.8% vs. 0%, p = 0.09). Evaluation of the clinical outcomes of 40 patients with early CKD and 11 patients with advanced CKD showed that the rate of recovery after treatment was significantly higher in the former than in the latter (92.5% vs. 63.6%, p = 0.02) (Table 4). Among early CKD patients who did not recover, 2 died and 1 developed exacerbation secondary to fluconazole but recovered after changing the treatment to voriconazole. All 4 patients with advanced CKD 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 present study found that immunosuppressive drug was used more often by patients with advanced CKD than by those with early CKD (Table 1). Because this might have affected the results, we performed multivariate analysis for the variables that were significantly different between patients with early CKD and those with advanced CKD. In the models that were stratified according to eGFR and use of immunosuppressive drug, the variables included fever, white blood cell count, serum albumin, and CRP. 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 advanced CKD, even after adjustment by the use of immunosuppressive drug (Table 5).