The guideline recommends prevention for patients with certain risk factors based on various clinical scenarios and the immunosuppressive regimen presented in the infographic. Some risk factors bear more weight than others, and clinical judgment is necessary for deciding.
The suggestion is to use PJP prophylaxis in patients with the following risk factors, irrespective of immunosuppressive regimen:
- Cytomegalovirus infection
- Lymphopenia (lymphocyte count < 0.5 x 109 cells/L) or low CD4 count (< 200 cells/microL)
- Prolonged neutropenia
Some authors consider hypogammaglobulinemia a risk factor for PJP. Still, it has not been included in these guidelines because it could lead to over-treatment in patients with nephrotic syndrome.
Trimethoprim/sulfamethoxazole (TMP/SMX) is the first-line drug of choice, based on its higher efficacy than other available prophylactic agents. Alternative agents include dapsone and the relatively more expensive options such as pentamidine (nebulized) and atovaquone.
Further, the recently published KDIGO 2021 guidelines provide general recommendations for PJP prophylaxis for patients on high-dose steroids or receiving cyclophosphamide and rituximab. Specific considerations for each glomerular disease are:
- Lupus nephritis. Consider patients receiving high-dose steroids—however, caution for higher risk of adverse events with sulfa drugs.
- Anti Glomerular Basement Membrane Disease. Consider for the duration of cyclophosphamide therapy.
- ANCA-associated vasculitis. Consider for the duration of cyclophosphamide therapy or six months after the last dose of rituximab (longer for ongoing steroid use).
- IgAN – consider while on prednisolone equivalent ≥0.5 mg/kg/d.