Clinical Features, Treatment Strategies, and Immune Profile Changes in Kidney Transplant Recipients With Clostridioides difficile Infection: A Real-World Retrospective Study

Abstract Background: Clostridioides difficile infection (CDI) is a major complication in kidney transplant recipients (KTRs) due to long-term immunosuppression, antibiotic exposure, and gut microbiota disruption. Evidence guiding its management remains limited. We evaluated real-world treatment strategies, including fecal microbiota transplantation (FMT), and immunological recovery in KTRs. Methods: We retrospectively evaluated 639 adult KTRs (January 2021–May 2023) at a Chinese transplant center, identifying 24 patients with laboratory-confirmed CDI. We systematically assessed clinical characteristics, CDI severity, baseline immunosuppression, treatment modalities, clinical outcomes, and immunological parameters, including inflammatory cytokines and peripheral lymphocyte subsets. Results: The incidence of post-transplant diarrhea was 20.7%, and CDI incidence was 3.8%. All patients received supportive therapy; targeted anti-CDI antibiotics were used infrequently. Four patients with refractory CDI (16.7%) underwent FMT without adverse events. Following therapy, patients showed significant reductions in serum IL-1β, IL-8, IFN-γ, and TNF-α levels (p < 0.05), accompanied by significant increases in CD3+ and CD3+CD8+ T-cell counts (p < 0.01). This suggests clinical improvement correlates with attenuated systemic inflammation and restored cellular immunity. Renal function and biochemical indices remained stable. During a 24- to 52-month follow-up, no CDI recurrences occurred. Conclusion: This real-world study provides insights into CDI management in KTRs, supporting the safety and potential therapeutic value of FMT in refractory cases. Resolution was associated with cytotoxic T-cell recovery and decreased inflammatory cytokines. Prospective studies are needed to define optimal individualized treatment strategies.