Death after transplantation; an analysis of sixty cases

Meta-Analysis and Systematic Literature Review of the Genus Pneumocystis in Pet, Farm, Zoo, and Wild Mammal Species

A systematic literature search on Pneumocystis in 276 pet, farm, zoo, and wild mammal species resulted in 124 publications originating from 38 countries that were analyzed descriptively and statistically, for which inclusion and exclusion criteria were exactly defined. The range of recorded Pneumocystis prevalence was broad, yet in half of the citations a prevalence of ≤25% was documented. Prevalence was significantly dependent on the method used for Pneumocystis detection, with PCR revealing the highest percentages. Pet animals showed the lowest median Pneumocystis prevalence, followed by farm, wild, and zoo animals. In contrast, pet and farm animals showed higher proportions of high-grade infection levels compared to zoo and wild mammals. Only in individual cases, all of them associated with severe Pneumocystis pneumonia, was an underlying immunosuppression confirmed. Acquired immunosuppression caused by other diseases was frequently discussed, but its significance, especially in highly immunosuppressive cases, needs to be clarified. This meta-analysis supported a potential influence of the social and environmental factors of the host on Pneumocystis transmission in wildlife, which must be further elucidated, as well as the genetic diversity of the fungus.

Prevention and Management of Tuberculosis in Solid Organ Transplant Recipients

Solid organ transplant recipients are at an increased risk of tuberculosis and transplant candidates should be screened early in their evaluation with a detailed history, tuberculin skin test or tuberculosis interferon-gamma release assay, and chest radiograph. For latent tuberculosis treatment, isoniazid and rifamycin-based regimens have advantages and disadvantages; treatment decisions should be customized. Tuberculosis after solid organ transplantation generally occurs after months or years; early infections should raise the possibility of donor-derived infections. Tuberculosis diagnosis and treatment in solid organ transplant recipients may be complicated by protean manifestations, drug interactions, and adverse drug reactions.

Successful Treatment of Tuberculosis in Renal Transplant Recipients1

Tuberculosis is a rare and usually fatal complication of renal transplantation. From 82 transplants in seven years, 4 cases of tuberculosis are reported. All have been treated successfully, with no fatalities or deterioration in renal function.

Exercise limitation following transplantation

Organ transplantation is one of the medical miracles or the 20th century. It has the capacity to substantially improve exercise performance and quality of life in patients who are severely limited with chronic organ failure. We focus on the most commonly performed solid-organ transplants and describe peak exercise performance following recovery from transplantation. Across all of the common transplants, evaluated significant reduction in VO2peak is seen (typically renal and liver 65%-80% with heart and/or lung 50%-60% of predicted). Those with the lowest VO2peak pretransplant have the lowest VO2peak posttransplant. Overall very few patients have a VO2peak in the normal range. Investigation of the cause of the reduction of VO2peak has identified many factors pre- and posttransplant that may contribute. These include organ-specific factors in the otherwise well-functioning allograft (e.g., chronotropic incompetence in heart transplantation) as well as allograft dysfunction itself (e.g., chronic lung allograft dysfunction). However, looking across all transplants, a pattern emerges. A low muscle mass with qualitative change in large exercising skeletal muscle groups is seen pretransplant. Many factor posttransplant aggravate these changes or prevent them recovering, especially calcineurin antagonist drugs which are key immunosuppressing agents. This results in the reduction of VO2peak despite restoration of near normal function of the initially failing organ system. As such organ transplantation has provided an experiment of nature that has focused our attention on an important confounder of chronic organ failure-skeletal muscle dysfunction.

The risk of tuberculosis transmission in solid organ transplantation: Is it more than a theoretical concern?

The present case report describes a therapeutic dilemma regarding the transmission of Mycobacterium tuberculosis during transplantation of solid organs, places this phenomenon within the context of the literature, and makes recommendations for screening and therapy.

Infections After Organ Transplantation

Over the last ten to fifteen years medical and surgical advances have led to lower rates of infection and infection-related mortality in transplant recipients. Despite these advances, the process whereby one diagnoses and manages infectious problems in transplant patients has become increasingly complex. Evaluation of transplant patients with infections requires a good understanding of the intricacies of modern immunosuppressive therapy and both the typical and atypical clinical manifestations of many conventional and opportunistic pathogens. In particular, it is incumbent upon the clinicians caring for transplant patients to be familiar with the biology of cytomegalovirus and other herpes viruses, and of the prophylactic strategies that have evolved to lessen the burden of disease from these agents. Thorough knowledge is also required of common fungal pathogens and the viruses that cause chronic hepatitis. Transplant patients also should always be evaluated in the temporal context of their transplant operation, because different diseases are prevalent at different times after transplantation. Since immunosuppressive drugs modify the clinical presentation of infections is important to maintain clinical vigilance and attend to even minor new symptoms. This chapter is designed to provide a relatively concise overview of transplant infections for intensivists or other clinicians who encounter transplant patients in their practice. The references encompass much of the classic transplant infectious disease literature; they are included, not only for citation, but as a bibliography for further study.

Changes in causes of death after renal transplantation, 1966 to 1987

This descriptive study was undertaken to examine survival and changes in cause of death after renal transplantation. One fourth (259) of the 1,022 patients who received a renal transplant between 1966 and 1987 at the University of Pennsylvania had died by January 1, 1988. Causes of death for 246 (96%) of the deceased patients were analyzed. Despite an increase in age and number of comorbid diseases before transplantation, posttransplant survival increased significantly over the study period. All-cause mortality rates at 1, 2, and 5 years decreased significantly. Infectious disease cumulative mortality rates at 1, 2, and 5 years also decreased between 1966 and 1985. No trend in the 1-, 2-, or 5-year cardiovascular disease cumulative mortality rates was detected. The decline in the rate of deaths due to infection led to a decrease in the proportion of infection-related deaths and an associated increase in the proportion of cardiovascular disease-related deaths. The reduction in mortality over the past 2 decades is associated with the simultaneous improvement in immunosuppression and treatment of infectious diseases.

Survey of antibiotic prophylaxis in European renal transplantation practice

Death and morbidity resulting from infection in the immunosuppressed patient following renal transplantation has been much reduced as immunosuppressive regimens have become less aggressive. Such complications, however, remain a considerable risk to transplant recipients and the use of prophylactic antibiotics has been advocated. This survey documents current practices and attitudes to the use of antibiotic prophylaxis in renal transplantation centres throughout Europe on the basis of response to a postal questionnaire.

The therapeutic use of azathioprine in renal transplantation

This review discusses the pharmacokinetics, mechanism of action, clinical use, toxicities, drug interactions, and possible approaches for therapeutic monitoring of azathioprine (AZA). The drug has been used extensively in posttransplant immunosuppressive protocols. Its therapeutic use is hampered by the development of toxicities, however, especially leukopenia, which is a common criterion for dosage adjustment. Azathioprine is rapidly converted in the liver and erythrocytes to 6-mercaptopurine (6MP), which is eventually metabolized to inactive 6-thiouric acid (6TU). The terminal half-lives of AZA and 6MP are 50 and 74 minutes, respectively. While renal dysfunction does not alter the disposition of AZA, hepatic insufficiency attenuates the pharmacologic activity. Immunosuppression depends on the formation of active intracellular thiopurine ribonucleotides, although AZA itself may block antigen recognition. Individualization of AZA regimens by determining tissue concentrations of thioguanine nucleotides, and plasma concentrations of AZA, 6MP, or 6TU may improve the risk:benefit ratio.

Infection in renal transplant recipients. Current approaches to diagnosis, therapy, and prevention

Despite dramatic improvements in patient and renal allograft survival, infections continue to be an important cause of post-transplantation morbidity and mortality. Most serious infections manifest clinically as febrile diseases, and immunosuppression-induced compromised cell-mediated immunity is the basis for the predominance of infections due to opportunistic intracellular microorganisms. Diagnostic evaluation is guided by the timing of fever after transplantation, epidemiologic factors, and evidence of specific organ system involvement. Although current therapy of bacterial and parasitic infections is usually effective, the management of deep-seated fungal infections remains highly unsatisfactory. Cytomegalovirus disease, the single most important infection in some transplant centers, frequently presents as a self-limited viral syndrome; however, multiple organs may be affected. New measures for the rapid diagnosis and treatment of this viral infection hold promise. A number of recommendations have been proposed to prevent infections in renal transplant recipients; however, continued progress will depend primarily upon further refinements in immunosuppressive therapy.

Infectious arthritis in renal transplant patients

Infectious complications in the renal transplant patient are common, and infecting agents include opportunistic organisms as well as common pathogens. However, we were only able to document 6 patients who had septic arthritis from more than 800 who received a renal transplant at our institution over an 18-year period. Furthermore, only 16 other cases of infectious arthritis have been reported in the literature. All of our patients had an apparent predisposing factor and 3 patients had prior infection with the same organism. The knee was the most commonly infected joint. The initial synovial fluid white blood cell count was usually greater than 30,000 cells/mm3, but 1 patient with viral arthritis initially had noninflammatory fluid. The peripheral blood white blood cell count may not be elevated. All of our cases of initial joint infection occurred by 18 months posttransplant. Blood cultures were positive in 3 of 4 patients with bacterial infection. Followup of these 6 patients averaged 4.3 years. Numerous other rheumatologic syndromes and disorders peculiar to the posttransplant period may mimic a septic joint. Consequently, despite the low frequency of occurrence of septic arthritis, persistent attention to the locomotor system in the transplant patient is warranted.

Aminoglycoside dosing in renal transplant patients. Comparison of nomogram and individualized pharmacokinetic methods in patients with shifting renal function

Serum amikacin concentrations were compared in infected renal transplant recipients that were compared in infected renal transplant recipients that were dosed using a creatinine-based nomogram (group I) or an individual computer-assisted pharmacokinetic dosing method (group II). A total of 30 treatment courses were administered. Mean postinfusion peak levels were 22 microgram/ml in group I and 23.4 microgram/ml in group II. Mean serum trough levels were 8.8 microgram/ml and 5.5 microgram/ml in groups I and II, respectively. Both peak and trough serum levels were significantly more often in the acceptable therapeutic (peak 20-32 microgram/ml) and nontoxic (through less than 10 microgram/ml) ranges in group 11 patients. Seventy-seven per cent of group II and 38% of group I peak levels were in the therapeutic range, while 87% of group II and 70% of group I trough levels were less than 10 microgram/ml. Ototoxicity developed with similar frequency in both groups and occurred significantly more often with a peak level greater than 32 microgram/ml. Declining renal function, usually as a result of allograft rejection, occurred in seven (44%) group I and only three (25%) group II patients but could not be exclusively related to amikacin in any patient. A serum trough level of greater than 10 microgram/ml was associated with an increased risk of declining renal function independent of other risk factors. Failures of aminoglycoside therapy are frequently associated with inadequate serum levels. Conversely, ototoxicity and nephrotoxicity may be related to elevated serum aminoglycoside concentrations. For these reasons, the computer-assisted pharmacokinetic dosing method should be used in septic surgical patients whose renal function is subject to sudden and unexpected changes.

Tuberculosis in patients undergoing maintenance haemodialysis and renal transplantation

The difficulty in diagnosis of tuberculosis in patients with chronic renal failure or on immunosuppressive therapy is discussed. Anti-tuberculous therapy was required in 19 out of 315 patients who received a renal transplant in the Urology Unit, Hammersmith Hospital, between February 1961 and December 1979. Twelve patients were from overseas. Their management and the effect of anti-tuberculous therapy on the immunosuppressed patient were also studied. The disease was treated successfully in 18 patients, even though there were problems with diagnosis. The patient who died had active tuberculosis on post-morten examination. Prophylaxis should be considered in patients who have had tuberculosis in the past and may have received inadequate treatment.

Intracranial infection in cardiac transplant recipients

Infections have produced most of the deaths in the Stanford cardiac transplant program. Of the first 182 transplant recipients, 27 developed nonviral intracranial infections: meningoencephalitis/abscess in 16 patients, meningitis in 9, and rhinocerebral phycomycoses in 2. The responsible organisms included aspergillus, toxoplasma, candida, klebsiella, cryptococcus, coccidioides, listeria, mucor, and rhizopus. Characteristically, the areas of meningoencephalitis and abscesses were multiple and deep seated. Intracranial infections were invariably associated with pulmonary or disseminated infection with same organism. Computed tomographic (CT) brain scans in patients with meningoencephalitis often showed minimal, nonspecific, low-density lesions which usually did not exhibit contrast enhancement. At surgery the lesions were found to differ from typical pyogenic abscesses in that capsules were not well developed, and the aspirate consisted of necrotic fragments of edematous white matter and inflammatory cells rather than liquefied pus. Aspergillus infections of the central nervous system usually developed within the first three months after transplantation. Cases of meningitis occurred at variable times after transplantation, but approximately half appeared within 30 days after immunosuppressive therapy for treatment of rejection was increased. The prognosis for brain abscess depended on the causative organism. All patients with aspergillus infection died despite treatment with amphotericin B. The toxoplasma abscess responded to a combination of sulfadiazine and pyrimethamine. Meningitis was successfully suppressed or cured with appropriate treatment except for 1 patient with disseminated cryptococcosis.

Successful treatment of Nocardia asteroides infection with minocycline in kidney transplant patients

Two cases of Noca dia asteroides infection were encountered out of 55 kidney transplant patients at Chiba University Hospital. One patient developed an extrapleural abscess and the other had a pulmonary infiltration with chest wall abscess. The patients were successfully treated by surgical drainage of the chest wall abscesses and by oral administration of minocycline. No adverse effects caused by minocycline were observed during the therapy. From 1900, when the first case of Nocardia infection was reported in Japan, there have been 60 cases reported in Japanese literature through 1973, including those we observed. This is the first report on nocardiosis in kidney transplant patients and on successful treatment of nocardiosis with minocycline in Japan.

Bacteremia after renal transplantation

Of 291 patients who received renal allotransplants in 1964-74, 94 patients developed 121 bacteremic episodes within the first 6 months after transplantation. The death rate was 38%. The bacteremic episodes occurred mainly during the first 2-3 months after transplantation. In 65% of the episodes bacteremia was secondary to urinary tract infections. The bacteria fourn were most often gram-negative rods such as Escherichia coli, Klebsiella and Proteus. Predisposing factors were ureteral complications such as leakage or necrosis of the ureter, leucopenia, immunosuppression, and source of the kidney. The frequency of bacteremia was the same in patients with infectious and non-infectious primary renal disease.

Infections complicating orthotopic liver transplantation: a study emphasizing graft-related septicemia

In 93 recipients of 102 orthotopic liver homografts, the incidence of bacteremia or fungemia exceeded 70%. The graft itself was usually an entry site for systemic infection after both immunologic and nonimmunologic parenchymal injury, especially if there was defective biliary drainage. The role of the homograft itself as the special infectious risk factor has prompted increased use of defunctionalized jejunal Roux limbs to reduce graft contamination. It has also stimulated very aggressive postoperative diagnostic efforts to rule out remedial mechanical complications of the transplant.

Diagnosis of cytomegalovirus pneumonia in compromised hosts

Sixteen patients with cytomegalovirus pulmonary infection are described. In 11 the diagnosis was made antemortem by lung aspirate or biopsy, and in five the diagnosis was made at postmortem by typical lung histology and positive viral lung cultures. All patients were immunosuppressed by both their underlying diseases and treatment with corticosteroids and other chemotherapy. Although other pathogens were identified at lung biopsy in most patients (73 per cent), primarily Pneumocystis carinii, evidence is offered to demonstrate that cytomegalovirus can cause significant pulmonary disease alone, leading to respiratory failure and death.

Factors in the differential rate of arteriosclerosis (AS) between long surviving renal transplant recipients and dialysis patients

In this study, the incidence of clinical and autopsy arteriosclerosis (AS) was studied in over 300 renal transplant patients (RTP) followed in our clinic up to 13 years post-transplant. Of 45 RTP followed a mean of 10.45 years, the incidence of clinical AS was 6% or 0.58% per year at risk. The incidence of death from AS was 2.2% over 10 years or 0.22% per year at risk. There was no apparent tendency for increase of the risk incidence with increasing time post-transplantation up to 13 years. This incidence of clinical and death-related AS in long term RTP contrasts sharply with a quite high incidence of both clinical and death-related AS in long-term dialysis patients as reported by Scribner's group and both the European and U.S. Dialysis Registry. Of our RTP surviving a decade or more, 77% have normal serum triglycerides and 92% are normotensive, again contrasting sharply with a 70-80% incidence of hyperlipidemia and a 60-80% incidence of hypertension in long-term dialysis patients. These studies suggest that the high rate of accelerated AS in dialysis patients is largely reversed by successful renal transplantation, probably due to a lowering of both blood pressure and hyperlipidemia in the long-term RT patients. Practically, these results suggest that the superior survival of transplant patients over dialysis patients already evident at 10 year mark will widen further during the second post-transplantation decade.

Tuberculosis after corticosteroid therapy

Fourteen episodes of reactivation of tuberculosis after corticosteroid administration are reported. In most a disease impairing the host defences was present and four were taking additional immunosuppressants. The most common presenting symptoms were productive cough and malaise. Bacteriological diagnosis required bronchoscopy in three cases. Response to antituberculosis therapy was good. Five of the 14 episodes manifested dissemination of pulmonary tuberculosis with four occurring in patients receiving high-dose corticosteroids and other immunosuppressants. No prolongation of sputum conversion time was noted in the patients. The published effects of corticosteroids on the tuberculous state are reviewed. Because INH administration may cause liver damage in a small minority of patients, a reassessment is required of the need for INH chemoprophylaxis when corticosteroids are used in patients with healed tuberculosis.

The incidence and management of pulmonary mycosis in renal allograft patients

A retrospective analysis of 193 renal transplant recipients yielded 15 patients who developed pulmonary mycosis posttransplantation and one case in which mycotic lung infection existed at the time of transplant surgery. Agent responsible for infection included Nocardia asteroides in 8 cases, Asperigillus flavus in 5 cases, Cryptococcus neoformans in 4 patients and Candida albicans in 2 cases. Two cases had mixed mycotic infections. Ten patients died, of which 7 had diagnosis established antemortem. Two cases had diagnosis established by thoracotomy and 1 case by transtracheal aspiration. Problems in establishing accurate diagnosis are discussed with emphasis placed on the need for more frequent use of transtracheal aspiration and thoracotomy for precise diagnosis.

Effect of glucocorticosteroids on the phagocytosis and intracellular killing by peritoneal macrophages

The effect of hydrocortisone on the phagocytosis and intracellular killing by mouse peritoneal macrophages in vitro was studied by a method making it possible to measure these processes separately. The results showed that in vivo treatment with 15 mg of hydrocortisone acetate did not significantly decrease the phagocytosis of several bacterial species such as Staphylococcus albus, Staphylococcus aureus, Escherichia coli, Salmonella typhimurium, and Pseudomonas aeruginosa. The killing indexes of normal macrophages for the various microorganisms were found to be significantly different. This may indicate that the bactericidal mechanisms are not uniform for these bacteria. The effect of hydrocortisone on the intracellular killing was also variable. For Staphylococcus albus a normal killing index was found. For the other species of bacterial and for Candida albicans some decrease was found, but this was only significant for Salmonella typhimurium. It is concluded that a decrease host resistance due to glucocorticosterioid treatment is not caused by a direct effect of these drugs on the phagocytosis and intracellular killing by mononuclear phagocytes.

Successful management of miliary tuberculosis after renal transplantation

Miliary tuberculosis is the most lethal form of tubercular disease. If dissemination of tubercle bacilli occurs without therapy, death is almost certain. The importance of establishing an etiologic diagnosis as promptly as possible in patients receiving immunosuppressive therapy is self-explanatory. The presence of a life-threatening infection in these patients requires aggressive antimicrobial therapy and discontinuation of the immunosuppressive drugs until the infectious process is under control; the presence of an impaired immunologic response is responsible for the life-threatening infection and the lack of an acute rejection reaction.

Hematogenous candida osteomyelitis. Report of three cases and review of the literature

Candida osteomyelitis of the spine and intervertebral disc developed in three patients without evidence of back trauma of overlying cutaneous infection. Two patients were prone to the development of disseminated candidiasis by the use of multiple antibiotics and other predisposing modalities following abdominal surgery. One patient had no identifiable cause for development of the infection. The diagnosis was established in all three cases by x-ray evidence of osteomyelitis and culture from needle aspirate. Two patients had bone scans consistent with infection. Each patient received different therapy. One was treated with amphotericin B, one with spinal fusion and 5-fluorocytosine, and one with no antifungal therapy. All patients had complete healing of the involved vertebrae. Candida organisms have the potential to cause destructive bone infection following hematogenous dissemination. The presence of Candida osteomyelitis may be helpful in diagnosing disseminated candidiasis.

Renal excretion of vancomycinin in kidney disease

The renal climination of vancomycin has been determined in 18 patients. In 4 anuric patients in intermittent haemodialysis the dosage of vancomycin necessary to treat infection with penicillin-resistantstrains of Staphylococcus aureus was determined. In 14 patients with varying degrees of renal insufficiency vancomycin, creatinine and 125-iothalamate clearances were measured and found to be closely correlated. After administration of the initial vancomycin dose and attainment of the serum concentration desired, the maintenance dose can be calculated on the basis of the GFR.

Serum IgG and renal transplantation

In 57 patients with renal allografts the prolonged administration of prednisolone >/= 1 mg/kg/day and azathioprine >/= 3 mg/kg/day caused a significant and persistent fall in serum IgG at all levels of creatinine clearance. The fall in IgG was more striking when creatinine clearance was below 25 ml/min. At lower doses of azathioprine and prednisolone serum IgG fell when the creatinine clearance was less than 35 ml/min, the degree of recovery towards normal being dependent on creatinine clearance and dosage. Post-transplant haemodialysis decreased the depression of IgG, and patients with immediately functioning grafts had minimal IgG depression. An inverse relation between IgG and IgM was observed in some patients. Severe infections and toxicity were associated with the greatest reduction in IgG; leucopenia and thrombocytopenia were not consistently reliable guides to toxicity. The deaths of four patients (7%) were associated with severe infections. Falls in IgG were not related to the rejection process. IgG measurement should be used as a guide to immunosuppression and toxicity in renal allograft patients.

5-Fluorocytosine in the treatment of experimental candidiasis in immunosuppressed mice

A model infection with Candida albicans was established in mice. The animals were pretreated for 1 week with azathioprine, given dexamethasone, and then infected intravenously with Candida. Mortality for the group given Candida infection alone was 20%, 38% when azathioprine was added, and 50% when dexamethasone and azathioprine were given with infection. The titers of Candida in most mice were 10(6) per gram of kidney. The rest of the mice were killed at 30 days. At this time, 16% had no evidence of Candida in the kidneys, but 40% of the mice had titers of 10(6) or more. Mice treated with 5-fluorocytosine had a mortality of less than 4% in 30 days. Five percent of the treated mice killed at 30 days had titers of Candida of 10(6). Therefore, 5-fluorocytosine increases survival in the presence of continued therapy with azathioprine with or without pretreatment with dexamethasone. The survival is associated with decreased titers of Candida in the kidneys.