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Acute respiratory failure in kidney transplant recipients: a multicenter study

Emmanuel Canet1, David Osman2, Jérome Lambert1, Christophe Guitton3, Anne-Elisabeth Heng4, Laurent Argaud5, Kada Klouche6, Georges Mourad6, Christophe Legendre7, Jean-François Timsit8, Eric Rondeau9, Maryvonne Hourmant10, Antoine Durrbach11, Denis Glotz12, Bertrand Souweine4, Benoît Schlemmer1 and Elie Azoulay1*

Author Affiliations

1 Medical Intensive Care Unit and Biostatistics Departments, Saint-Louis Teaching Hospital, 1 avenue Claude Vellefaux, Paris F-75010, France

2 Medical Intensive Care Unit, Bicêtre Teaching Hospital, 78 rue du Général Leclerc, Kremlin-Bicêtre F-94275, France

3 Medical Intensive Care Unit, Hôtel-Dieu Teaching Hospital, Place Alexis Ricordeau, Nantes, 44093, France

4 Departments of Intensive Care Medicine, Nephrology and Transplantation, Gabriel Montpied Teaching Hospital, 58 rue Montalembert, Clermont-Ferrand F-63003, France

5 Medical Intensive Care Unit, Edouard Herriot Teaching Hospital, 5 Place d'Arsonval, Lyon, 69437, France

6 Medical Intensive Care Unit, Nephrology and Transplantation, Lapeyronnie Teaching Hospital, 371 Avenue du doyen Gaston Giraud, Montpellier F-34295, France

7 Department of Nephrology and Transplantation, Necker Teaching Hospital, 149 rue de Sèvres, Paris F-75743, France

8 Medical Intensive Care Unit, A. Michallon Teaching Hospital, Avenue de Chantourne, Grenoble F-38043, France

9 Department of Nephrology and Transplantation, Tenon Teaching Hospital, 4 Rue de la Chine, Paris F-75970, France

10 Department of Nephrology and Transplantation, Hôtel-Dieu Teaching Hospital, Place Alexis Ricordeau, Nantes F-44093, France

11 Nephrology and Transplantation, Bicêtre Teaching Hospital, 78 rue du Général Leclerc, Kremlin-Bicêtre F-94275, France

12 Department of Nephrology and Transplantation, Saint-Louis Teaching Hospital, 1 avenue Claude Vellefaux, Paris F-75010, France

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Critical Care 2011, 15:R91  doi:10.1186/cc10091

Published: 8 March 2011

Abstract

Introduction

Data on pulmonary complications in renal transplant recipients are scarce. The aim of this study was to evaluate acute respiratory failure (ARF) in renal transplant recipients.

Methods

We conducted a retrospective observational study in nine transplant centers of consecutive kidney transplant recipients admitted to the intensive care unit (ICU) for ARF from 2000 to 2008.

Results

Of 6,819 kidney transplant recipients, 452 (6.6%) required ICU admission, including 200 admitted for ARF. Fifteen (7.5%) of these patients had combined kidney-pancreas transplantations. The most common causes of ARF were bacterial pneumonia (35.5%), cardiogenic pulmonary edema (24.5%) and extrapulmonary acute respiratory distress syndrome (ARDS) (15.5%). Pneumocystis pneumonia occurred in 11.5% of patients. Mechanical ventilation was used in 93 patients (46.5%), vasopressors were used in 82 patients (41%) and dialysis was administered in 104 patients (52%). Both the in-hospital and 90-day mortality rates were 22.5%. Among the 155 day 90 survivors, 115 patients (74.2%) were dialysis-free, including 75 patients (65.2%) who recovered prior renal function. Factors independently associated with in-hospital mortality were shock at admission (odds ratio (OR) 8.70, 95% confidence interval (95% CI) 3.25 to 23.29), opportunistic fungal infection (OR 7.08, 95% CI 2.32 to 21.60) and bacterial infection (OR 2.53, 95% CI 1.07 to 5.96). Five factors were independently associated with day 90 dialysis-free survival: renal Sequential Organ Failure Assessment (SOFA) score on day 1 (OR 0.68/SOFA point, 95% CI 0.52 to 0.88), bacterial infection (OR 0.43, 95% CI 0.21 to 0.90), three or four quadrants involved on chest X-ray (OR 0.44, 95% CI 0.21 to 0.91), time from hospital to ICU admission (OR 0.98/day, 95% CI 0.95 to 0.99) and oxygen flow at admission (OR 0.93/liter, 95% CI 0.86 to 0.99).

Conclusions

In kidney transplant recipients, ARF is associated with high mortality and graft loss rates. Increased Pneumocystis and bacterial prophylaxis might improve these outcomes. Early ICU admission might prevent graft loss.