*Purpose: Cryptococcosis is the third most common invasive fungal infection in organ transplant recipients.The clinical approach and prognosis has been previously investigated in the setting of solid organ transplantation, however the outcomes pertaining to kidney transplant patients has yet to be addressed specifically. We sought to assess kidney graft function following cryptococcosis and initial disease presentation.

*Methods: We performed a retrospective case-control study of adult patients diagnosed with cryptococcosis after kidney transplantation between 2002 and 2018 in France. One control patient was matched per case according to institution and transplant date.

*Results: Sixty patients were included. Patients were predominantly male (70 %) and were more likely to be highly sensitized (65%) compared to controls (22%, p<0.001). The median duration of follow-up from the date of cryptococcosis was 17 months [2.75 - 45.75 months]Two-year all-cause mortality was significantly higher in patients with cryptococcosis (43 %) than in control transplant patients (n=11/158, 6.9%) (p = 0.0001).Compared to the control group, patients who survived cryptococcosis had a higher risk of end-stage kidney disease [(25/53) vs (3/36) p = 0.003] and a lower kidney function (eGFR based on CKD-EPI: 35.5 ml/min/1.73m² [8-69] vs 47.3 ml/min/1,73m²[15-89], p=0.03). Mechanisms of kidney graft function deterioration consisted chiefly in chronic graft dysfunction following cryptococcosis (n=5/43, 12%), graft rejection (n=4/43, 9%) and viral nephritis (n=3/43, 7%). 57 % of the patients presented with disseminated cryptococcosis or disease involving the central nervous system. 32% had pulmonary disease and 9 % had skin, soft-tissue, osteoarticular or urinary tract cryptococcosis. Canonical symptoms such as headaches and vomiting were mostly absent, affecting 45% of and 22% of the patients, respectively. The presence of fever was inconsistent (63%). Accordingly, 82% of the patients had a history of prior hospitalization for inaugural symptoms of cryptococcosis without a conclusive diagnosis being established, amounting to median diagnosis delay time of 35 days [9 -61 days].

*Conclusions: Cryptococcosis is associated with a negative impact on kidney transplant patients survival and kidney graft outcomes. Multiple causes of graft loss were identified including conditions connected to both over-immunosuppression and under-immunosuppression. Characteristic features pertaining to cryptococcosis may be missing upon inaugural presentation resulting in delayed diagnosis and increased morbidity.

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