背景:克氏锥虫再激活的风险知之甚少。先前评估再激活风险的研究报告不精确的发现,临床指南的监测和管理建议依赖于共识意见.
目的:我们进行了系统评价和荟萃分析,以估计免疫抑制成人的累积克氏锥虫再激活发生率,总结了有关再激活的预后因素的可用证据,并检查其对死亡率的预后影响。
方法:MEDLINE,Embase和LILACS,临床试验,和CENTRAL从成立到2022年7月4日。
方法:报告克氏毛虫再激活发生率的研究。
方法:慢性克氏锥虫感染的免疫抑制成人。
方法:两位作者独立提取数据(包括,但不限于,发病率数据,重新激活定义,后续行动,治疗,监控时间表,检查预后因素)并评估偏倚风险。我们使用随机效应模型汇总了累积发病率。
结果:包括22项研究(806名参与者)。克氏锥虫再激活的总合并发生率为27%(95%CI19-36),移植受者亚组的合并比例最高(36%,95%CI25-48)。最高的危险期是移植后的前六个月(32%,95%CI17-58),之后大幅减少新病例的数量。HIV感染者和自身免疫性疾病患者的累积再激活发生率显着降低(17%,95%CI8-29;和18%,95%CI9-29;分别)。一项研究探索了苯并硝唑的独立作用,并发现了预防再激活的益处。没有研究评估再激活和死亡率之间的独立关联,而使用未调整估计值的敏感性分析结果尚无定论.诊断算法的异质性很大。
结论:在十个克氏锥虫血清阳性的免疫抑制成人中,有三个发生了再激活。这些发现可以帮助临床医生和小组指南调整监测时间表。非常需要重新激活和有针对性的监测的准确定义。
BACKGROUND: The risk of Trypanosoma cruzi
reactivation is poorly understood. Previous studies evaluating the risk of reactivation report imprecise findings, and recommendations for monitoring and management from clinical guidelines rely on consensus opinion.
OBJECTIVE: We conducted a systematic
review and meta-analysis to estimate the cumulative T. cruzi reactivation incidence in immunosuppressed adults, summarize the available evidence on prognostic factors for
reactivation, and examine its prognostic effect on mortality.
METHODS: MEDLINE, Embase, LILACS, Clinical Trials, and CENTRAL from inception to 4 July 2022.
METHODS: Studies reporting the incidence of T. cruzi
reactivation.
METHODS: Immunosuppressed adults chronically infected by T. cruzi.
METHODS: Two authors independently extracted data (including, but not limited to, incidence data, reactivation definition, follow-up, treatment, monitoring schedule, examined prognostic factors) and evaluated the risk of bias. We pooled cumulative incidence using a random-effects model.
RESULTS: Twenty-two studies (806 participants) were included. The overall pooled incidence of T. cruzi reactivation was 27% (95% CI, 19-36), with the highest pooled proportion in the sub-group of transplant recipients (36%; 95% CI, 25-48). The highest risk period was in the first 6 months after transplant (32%; 95% CI, 17-58), decreasing drastically the number of new cases later. People living with HIV and patients with autoimmune diseases experienced significantly lower cumulative reactivation incidences (17%; 95% CI, 8-29 and 18%; 95% CI, 9-29, respectively). A single study explored the independent effect of benznidazole and found benefits for preventing reactivations. No studies evaluated the independent association between reactivation and mortality, while sensitivity analysis results using unadjusted estimates were inconclusive. The heterogeneity of diagnostic algorithms was substantial.
CONCLUSIONS: Reactivation occurs in three out of ten T. cruzi-seropositive immunosuppressed adults. These findings can assist clinicians and panel guidelines in tailoring monitoring schedules. There is a great need for an accurate definition of
reactivation and targeted monitoring.