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Gadde AB, Jha PK, Bansal SB, Rana A, Jain M, Bansal D, Yadav DK, Mahapatra AK, Sethi SK, Kher V. Renal Transplantation in Patients With Tuberculosis: A Single-center Experience From an Endemic Region. Transplant Direct 2023; 9:e1541. [PMID: 37915462 PMCID: PMC10617933 DOI: 10.1097/txd.0000000000001541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 07/18/2023] [Accepted: 08/01/2023] [Indexed: 11/03/2023] Open
Abstract
Background Despite being a common infection in end-stage kidney disease patients, there are no evidence-based guidelines to suggest the ideal time of transplantation in patients on antitubercular therapy (ATT). This study aimed to examine the outcome of transplantation in patients while on ATT compared with those without tuberculosis (TB). Methods This was a retrospective study. Renal transplant recipients transplanted while on ATT were compared with a 1:1 matched group (for age, sex, diabetic status, and type of induction agent) of patients without TB at the time of transplant. Patient outcomes included relapse of TB and graft and patient survival. Results There were 71 patients in each group. The mean duration for which ATT was given pretransplant was 3.8 ± 2.47 mo. The average total duration of ATT received was 12.27 ± 1.25 mo. Mortality in both the groups was similar (8.4% in the TB group versus 4.5% in the non-TB group; P = 0.49). None of the surviving patients had recurrence of TB during the follow-up. Death-censored graft survival (98.5% in the TB group versus 97% in the non-TB group; P = 1) and biopsy-proven acute rejection rates (9.86% in the TB group versus 8.45% in the non-TB group; P = 1) were also similar in both the groups. Conclusions Successful transplantation in patients with end-stage kidney disease on ATT is possible without any deleterious effect on patient and graft survival and no risk of disease recurrence. Multicentric prospective studies are needed.
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Affiliation(s)
- Ashwini B. Gadde
- Department of Nephrology and Renal Transplant, Medanta–The Medicity, Gurugram, India
| | - Pranaw Kumar Jha
- Department of Nephrology and Renal Transplant, Medanta–The Medicity, Gurugram, India
| | - Shyam B. Bansal
- Department of Nephrology and Renal Transplant, Medanta–The Medicity, Gurugram, India
| | - Abhyudaysingh Rana
- Department of Nephrology and Renal Transplant, Medanta–The Medicity, Gurugram, India
| | - Manish Jain
- Department of Nephrology and Renal Transplant, Medanta–The Medicity, Gurugram, India
| | - Dinesh Bansal
- Department of Nephrology and Renal Transplant, Medanta–The Medicity, Gurugram, India
| | - Dinesh Kumar Yadav
- Department of Nephrology and Renal Transplant, Medanta–The Medicity, Gurugram, India
| | - Amit Kumar Mahapatra
- Department of Nephrology and Renal Transplant, Medanta–The Medicity, Gurugram, India
| | - Sidharth Kumar Sethi
- Department of Nephrology and Renal Transplant, Medanta–The Medicity, Gurugram, India
| | - Vijay Kher
- Department of Nephrology and Renal Transplant, Medanta–The Medicity, Gurugram, India
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Sorohan BM, Ismail G, Tacu D, Obrișcă B, Ciolan G, Gîngu C, Sinescu I, Baston C. Mycobacterium Tuberculosis Infection after Kidney Transplantation: A Comprehensive Review. Pathogens 2022; 11:pathogens11091041. [PMID: 36145473 PMCID: PMC9505385 DOI: 10.3390/pathogens11091041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 09/10/2022] [Accepted: 09/12/2022] [Indexed: 11/18/2022] Open
Abstract
Tuberculosis (TB) in kidney transplant (KT) recipients is an important opportunistic infection with higher incidence and prevalence than in the general population and is associated with important morbidity and mortality. We performed an extensive literature review of articles published between 1 January 2000 and 15 June 2022 to provide an evidence-based review of epidemiology, pathogenesis, diagnosis, treatment and outcomes of TB in KT recipients. We included all studies which reported epidemiological and/or outcome data regarding active TB in KT, and we approached the diagnostic and treatment challenges according to the current guidelines. Prevalence of active TB in KT recipients ranges between 0.3–15.2%. KT recipients with active TB could have a rejection rate up to 55.6%, a rate of graft loss that varies from 2.2% to 66.6% and a mortality rate up to 60%. Understanding the epidemiological risk, risk factors, transmission modalities, diagnosis and treatment challenges is critical for clinicians in providing an appropriate management for KT with TB. Among diagnostic challenges, which are at the same time associated with delay in management, the following should be considered: atypical clinical presentation, association with co-infections, decreased predictive values of screening tests, diverse radiological aspects and particular diagnostic methods. Regarding treatment challenges in KT recipients with TB, drug interactions, drug toxicities and therapeutical adherence must be considered.
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Affiliation(s)
- Bogdan Marian Sorohan
- Department of Kidney Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of General Medicine, Carol Davila University of Medicine and Pharmacy, 020022 Bucharest, Romania
- Correspondence: ; Tel.: +40-740156198
| | - Gener Ismail
- Department of General Medicine, Carol Davila University of Medicine and Pharmacy, 020022 Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Dorina Tacu
- Department of Kidney Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Bogdan Obrișcă
- Department of General Medicine, Carol Davila University of Medicine and Pharmacy, 020022 Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Gina Ciolan
- Department of Pneumology, Marius Nasta National Institute of Pneumology, 050159 Bucharest, Romania
| | - Costin Gîngu
- Department of Kidney Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of General Medicine, Carol Davila University of Medicine and Pharmacy, 020022 Bucharest, Romania
| | - Ioanel Sinescu
- Department of Kidney Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of General Medicine, Carol Davila University of Medicine and Pharmacy, 020022 Bucharest, Romania
| | - Cătălin Baston
- Department of Kidney Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of General Medicine, Carol Davila University of Medicine and Pharmacy, 020022 Bucharest, Romania
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Schmidt-Lauber C, Jacobi J, Polifka I, Hilgers KF, Wiesener MS. Suspected colonic cancer turns out to be disseminated tuberculosis in a kidney transplant recipient: A case report. Medicine (Baltimore) 2019; 98:e16995. [PMID: 31490381 PMCID: PMC6738975 DOI: 10.1097/md.0000000000016995] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
RATIONALE Active tuberculosis constitutes a relevant risk for kidney transplant recipients. In contrast to immunocompetent hosts, kidney transplant recipients often show atypical presentation and course of the disease impeding diagnosis. Especially extrapulmonary or disseminated infection is more frequent and can resemble malignant processes. However, reactivation of tuberculosis mostly develops within the early post-transplant course, whereas malignancies are predominantly long-term complications. We report a case of disseminated abdominal tuberculosis developing 10 years after kidney transplantation and review the underlying literature. PATIENT CONCERNS AND DIAGNOSES A 51-year-old lady presented with epigastric pain, diarrhea, weight loss and night sweats 10 years after deceased-donor kidney transplantation. An epigastric as well as multiple peritoneal masses were found suspicious of a cancer of unknown primary. Colonoscopy revealed a colon tumor with the biopsy showing no dysplasia but histiocytic and granulomatous infiltration with acid-fast bacilli. Mycobacterium tuberculosis was detected in the biopsy and stool and disseminated abdominal tuberculosi was diagnosed. INTERVENTIONS AND OUTCOMES With anti-tuberculosis therapy, the masses regressed, and all cultures became sterile, sparing graft function. LESSONS This case emphasizes how variable and unspecific the presentation of tuberculosis in kidney transplant recipients may be and that tuberculosis constitutes a relevant risk also in the long-term post-transplant course.
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Affiliation(s)
| | | | - Iris Polifka
- Department of Pathology, University of Erlangen-Nürnberg, Erlangen, Germany
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Maciel MMMD, Ceccato MDG, Carvalho WDS, Navarro PDD, Farah KDP, Miranda SSD. Prevalence of latent Mycobacterium tuberculosis infection in renal transplant recipients. J Bras Pneumol 2019; 44:461-468. [PMID: 30726322 PMCID: PMC6459744 DOI: 10.1590/s1806-37562017000000367] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 04/10/2018] [Indexed: 01/14/2023] Open
Abstract
Objective: To estimate the prevalence of latent Mycobacterium tuberculosis infection (LTBI) in renal transplant recipients and to assess sociodemographic, behavioral, and clinical associations with positive tuberculin skin test (TST) results. Methods: This was a cross-sectional study of patients aged ≥ 18 years who underwent renal transplantation at the Renal Transplant Center of the Federal University of Minas Gerais Hospital das Clínicas, located in the city of Belo Horizonte, Brazil. We included renal transplant recipients who underwent the TST between January 2011 and July 2013. If the result of the first TST was negative, a second TST was administered. Bivariate and multivariate analyses using logistic regression were used to determine factors associated with positive TST results. Results: The sample included 216 patients. The prevalence of LTBI was 18.5%. In the multivariate analysis, history of contact with a tuberculosis case and preserved graft function (estimated glomerular filtration rate ≥ 60 mL/min/1.73 m2) were associated with positive TST results. TST induration increased by 5.8% from the first to the second test, which was considered significant (p = 0.012). Conclusions: The prevalence of LTBI was low in this sample of renal transplant recipients. The TST should be administered if renal graft function is preserved. A second TST should be administered if the first TST is negative.
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Affiliation(s)
- Mônica Maria Moreira Delgado Maciel
- . Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil.,. Grupo de Transplante Renal, Hospital de Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil
| | | | | | | | - Kátia de Paula Farah
- . Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil
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Goletti D, Petrone L, Ippolito G, Niccoli L, Nannini C, Cantini F. Preventive therapy for tuberculosis in rheumatological patients undergoing therapy with biological drugs. Expert Rev Anti Infect Ther 2018; 16:501-512. [PMID: 29848120 DOI: 10.1080/14787210.2018.1483238] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Latent tuberculosis infection (LTBI) accounts for almost a quarter of the world population, and, in 5-10% of the subjects with impaired immune-response against M. tuberculosis growth, it may progress to active tuberculosis (TB). In this review, we focus on the need to propose a screening for LTBI including preventive therapy offer in rheumatic patients undergoing therapy with biological drugs. Areas covered: We report on evidence that biologics are associated with an increased risk of active TB reactivation. This effect seems to be mainly limited to treatment with anti-tumor necrosis factor (TNF) agents, while non-anti-TNF-targeted biologics are not likely associated to any increased risk. We introduce the concept that the patients' coexisting host-related risk factors, such as comorbidities, are crucial to identify those at higher risk to reactivate TB. We report that preventive TB therapy is well tolerated in patients treated with biological drugs. Expert commentary: Availability of non-anti-TNF targeted biologics, that are not associated with an increased risk of TB reactivation, offers a great opportunity to tailor a therapeutic intervention at low/absent TB risk. After proper LTBI screening investigations, preventive TB therapy has been demonstrated to be effective and well-tolerated to reduce the risk of TB reactivation in rheumatic patients requiring biological drugs.
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Affiliation(s)
- Delia Goletti
- a Translational Research Unit, Department of Epidemiology and Preclinical Research , "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS , Rome , Italy
| | - Linda Petrone
- a Translational Research Unit, Department of Epidemiology and Preclinical Research , "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS , Rome , Italy
| | - Giuseppe Ippolito
- b Scientific Direction, "L. Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS , Rome , Italy
| | - Laura Niccoli
- c Department of Rheumatology , Hospital of Prato , Prato , Italy
| | - Carlotta Nannini
- c Department of Rheumatology , Hospital of Prato , Prato , Italy
| | - Fabrizio Cantini
- c Department of Rheumatology , Hospital of Prato , Prato , Italy
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Abad CLR, Razonable RR. Mycobacterium tuberculosis after solid organ transplantation: A review of more than 2000 cases. Clin Transplant 2018; 32:e13259. [PMID: 29656530 DOI: 10.1111/ctr.13259] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Mycobacterium tuberculosis (TB) is a common pathogen worldwide, and it may cause significant infection after solid organ transplantation (SOT). We reviewed all reported TB cases to provide an update on its epidemiology, clinical presentation, management, and outcome after SOT. METHODS MEDLINE, EMBASE, and OVID were reviewed from January 1, 1998, to December 31, 2016, using keywords tuberculosis and solid organ transplant or transplantation. RESULTS There were 187 publications reporting 2082 cases of TB among kidney (n = 1719), liver (n = 253), heart (n = 77), lung (n = 25), and kidney-pancreas (n = 8) recipients. Among cohort studies, the median incidence was 2.37% (range, 0.05%-13.27%) overall. Most TB disease was considered reactivation of latent infection, occurring beyond the first year after SOT. Early-onset cases were seen among donor-derived TB cases. Fever was the most common symptom. Radiologic findings were highly variable. Extrapulmonary and disseminated TB occurred 29.84% and 15.96%, respectively. Multidrug-resistant TB was rare. Treatment using 4 or 5 drugs was commonly associated with hepatotoxicity and graft dysfunction. All-cause mortality was 18.84%. CONCLUSIONS This large review highlights the complexity of TB after SOT. Reactivation TB, donor-transmitted infection, extrapulmonary involvement, and disseminated disease are common occurrences. Treatment of TB is commonly associated with hepatotoxicity and graft dysfunction.
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Affiliation(s)
- Cybele Lara R Abad
- Section of Infectious Diseases, Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Raymund R Razonable
- Division of Infectious Diseases, Department of Medicine, The William J Von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine and Sciences, Rochester, MN, USA
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Cobelens F, Nagelkerke N, Fletcher H. The convergent epidemiology of tuberculosis and human cytomegalovirus infection. F1000Res 2018; 7:280. [PMID: 29780582 PMCID: PMC5934687 DOI: 10.12688/f1000research.14184.2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2018] [Indexed: 12/28/2022] Open
Abstract
Although several factors are known to increase the risk of tuberculosis, the occurrence of tuberculosis disease in an infected individual is difficult to predict. We hypothesize that active human cytomegalovirus infection due to recent infection, reinfection or reactivation plays an epidemiologically relevant role in the aetiology of tuberculosis by precipitating the progression from latent tuberculosis infection to disease. The most compelling support for this hypothesis comes from the striking similarity in age-sex distribution between the two infections, important because the age-sex pattern of tuberculosis disease progression has not been convincingly explained. Cytomegalovirus infection and tuberculosis have other overlapping risk factors, including poor socio-economic status, solid organ transplantation and, possibly, sexual contact and whole blood transfusion. Although each of these overlaps could be explained by shared underlying risk factors, none of the epidemiological observations refute the hypothesis. If this interaction would play an epidemiologically important role, important opportunities would arise for novel approaches to controlling tuberculosis.
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Affiliation(s)
- Frank Cobelens
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Meibergdreef 9, AZ, Amsterdam, 1105, Netherlands
| | - Nico Nagelkerke
- Department of Medical Microbiology, University of Manitoba, Basic Medical Sciences Building, 745 Bannatyne Avenue, Winnipeg, MB , R3E 0J9, Canada
| | - Helen Fletcher
- TB Centre, London School of Hygiene & Tropical Medicine, Keppel Street , London , WC1E 7HT, UK
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8
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Cobelens F, Nagelkerke N, Fletcher H. The convergent epidemiology of tuberculosis and human cytomegalovirus infection. F1000Res 2018; 7:280. [PMID: 29780582 PMCID: PMC5934687 DOI: 10.12688/f1000research.14184.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2018] [Indexed: 03/25/2024] Open
Abstract
Although several factors are known to increase the risk of tuberculosis, the occurrence of tuberculosis disease in an infected individual is difficult to predict. We hypothesize that active human cytomegalovirus infection due to recent infection, reinfection or reactivation plays an epidemiologically relevant role in the aetiology of tuberculosis by precipitating the progression from latent tuberculosis infection to disease. The most compelling support for this hypothesis comes from the striking similarity in age-sex distribution between the two infections, important because the age-sex pattern of tuberculosis disease progression has not been convincingly explained. Cytomegalovirus infection and tuberculosis have other overlapping risk factors, including poor socio-economic status, sexual contact, whole blood transfusion and solid organ transplantation. Although each of these overlaps could be explained by shared underlying risk factors, none of the epidemiological observations refute the hypothesis. If this interaction would play an epidemiologically important role, important opportunities would arise for novel approaches to controlling tuberculosis.
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Affiliation(s)
- Frank Cobelens
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Meibergdreef 9, AZ, Amsterdam, 1105, Netherlands
| | - Nico Nagelkerke
- Department of Medical Microbiology, University of Manitoba, Basic Medical Sciences Building, 745 Bannatyne Avenue, Winnipeg, MB , R3E 0J9, Canada
| | - Helen Fletcher
- TB Centre, London School of Hygiene & Tropical Medicine, Keppel Street , London , WC1E 7HT, UK
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9
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Al-Mukhaini SM, Al-Eid H, Alduraibi F, Hakami HI, Talhi HA, Shoukri M, Ahmed AM, Ahmed Y, Alrajhi AA. Mycobacterium tuberculosis in solid organ transplantation: incidence before and after expanded isoniazid prophylaxis. Ann Saudi Med 2017; 37:138-143. [PMID: 28377543 DOI: 10.5144/0256-4947.2017.138] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The risk of tuberculosis is increased in solid organ transplantation. Rates remain high in developed and developing countries. We developed protocols to better identify transplant recipients at risk of tuberculosis and initiate interventions to prevent tuberculosis. OBJECTIVES Report tuberculosis incidence in solid-organ transplant recipients and the results of expanded isoniazid prophylaxis in deceased-donor renal transplantation. DESIGN Retrospective cohort study, comparing two time periods. SETTING Large transplantation center in a WHO-medium endemicity country for tuberculosis. METHODS In a cohort of all solid-organ transplant recipients performed between 2003 and 2012, tuberculosis-free transplantation follow-up is used for incidence calculation. Rates of tuberculosis in renal transplant recipients are compared before and after implementation of expanded isoniazid prophylaxis. MAIN OUTCOME MEASURE(S) Active tuberculosis post-transplantation. RESULTS Of 1966 solid-organ transplant recipients (kidney: 1391, liver: 426, heart: 114, lung: 35), 20 recipients (1.02%) developed tuberculosis. Twelve cases (60%) developed tuberculosis within one year of transplantation. The incidence was 248 cases per 100 000 transplant-years. The proportion of transplant recipients (incidence of tuberculosis per 100 000 transplant-years) for specific organs were kidney 0.58% (127), liver 1.88% (594), heart: 1.75% (570), and lung 5.71% (4750). In the survival analysis, lung transplant recipients had significantly higher rates of tuberculosis compared to recipients of kidneys from living donors (P=.0001) with a rate ratio of 45.3 (95% CI: 7-313). Mortality was 5% among tuberculosis patients. After implementing expanded isoniazid prophylaxis among deceased-donor kidney recipients, no tuberculosis occurred in 177 recipients, compared to 3 out of 155 (2%) recipients before implementation. CONCLUSIONS Rates of tuberculosis among our solid transplant recipients are decreasing. Universal iso-niazid prophylaxis in transplant recipients could reduce transplant-associated tuberculosis in endemic areas. LIMITATIONS Donor data on tuberculosis exposure and prevention and tuberculosis prevention efforts before referral to our center are not available for all patients.
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Affiliation(s)
- Suad Mohamed Al-Mukhaini
- Dr. Suad Mohamed Al-Mukhaini, Sur Hospital Medicine,, South Sharqia,, PO Box 955 Sur, 411, Oman, T: 968 25561100,, F: 968 25561561, , ORCID: http://orcid.org/0000-0003-0646-4378
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10
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Fox GJ, Dobler CC, Marais BJ, Denholm JT. Preventive therapy for latent tuberculosis infection-the promise and the challenges. Int J Infect Dis 2016; 56:68-76. [PMID: 27872018 DOI: 10.1016/j.ijid.2016.11.006] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 11/07/2016] [Accepted: 11/08/2016] [Indexed: 02/03/2023] Open
Abstract
Around one third of the world's population may harbour latent tuberculosis infection (LTBI), an asymptomatic immunological state that confers a heightened risk of subsequently developing tuberculosis (TB). Effectively treating LTBI will be essential if the End TB Strategy is to be realized. This review evaluates the evidence in relation to the effectiveness of preventive antibiotic therapy to treat LTBI due to both drug-susceptible and drug-resistant bacteria. Current national and international preventive therapy guidelines are summarized, as well as ongoing randomized trials evaluating regimens to prevent drug-resistant TB. Populations that may benefit most from screening and treatment for LTBI include close contacts of patients with TB (particularly children under 5 years of age) and individuals with substantial immunological impairment. The risks and benefits of treatment must be carefully balanced for each individual. Electronic decision support tools offer one way in which clinicians can help patients to make informed decisions. Modelling studies indicate that the expanded use of preventive therapy will be essential to achieving substantial reductions in the global TB burden. However, the widespread scale-up of screening and treatment will require careful consideration of cost-effectiveness, while ensuring the drivers of ongoing disease transmission are also addressed.
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Affiliation(s)
- G J Fox
- Sydney Medical School, Room 574 Blackburn Building, University of Sydney, Sydney, 2006, Australia.
| | - C C Dobler
- Sydney Medical School, Room 574 Blackburn Building, University of Sydney, Sydney, 2006, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - B J Marais
- The Children's Hospital at Westmead and the Marie Bashir Institute for Infectious Diseases and Biosecurity (MBI), University of Sydney, Sydney, Australia
| | - J T Denholm
- Victorian Tuberculosis Program, Melbourne Health, Victoria, Australia; Department of Microbiology and Immunology, University of Melbourne, Parkville, Victoria, Australia
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11
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Volynchik EP, Bogomolova NS, Goryainov VA. [Types of infectious complications exciters in recipients of related kidneys]. Khirurgiia (Mosk) 2016:45-51. [PMID: 27271719 DOI: 10.17116/hirurgia2016545-51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
AIM To investigate the nature of microflora causing an infectious-inflammatory complications in recipients of related kidney in the early postoperative period and to substantiate the effectiveness of antibiotic prophylaxis and antibiotic therapy depending on pathogen type with the determination of its sensitivity to antimicrobial agents. MATERIAL AND METHODS The medical records of 255 patients who underwent kidney transplantation from a living related donor from 2007 to 2014 were analyzed. Foci of infection were sanitized preoperatively to prevent infectious complications in post-transplantation period. Immunosuppression induction was achieved using 2-fold administration of Kempas or Simulect. Corticosteroids, ciclosporin, prograf, advagraf, myfortic, neoral, sertican were used for routine immunosuppression. Complications after kidney transplantation were detected in 65 (25.5%) patients including 38 (14.9%) infectious and 27 (10.6%) non-infectious complications. The material for microbiological examination included blood, urine, sputum, wound discharge, bronchial lavage. Extraction and identification of microorganisms were carried out according to conventional techniques as well as using automatic Vitec-2 Compact analizer («BioMeriex», France). Sensitivity to antibiotics was determined using Vitek-2 Compact analyzer. The functional aspects of transplanted kidney were studied in 255 patients. Normal and decreased function of kidney was observed in 221 (86.6%) and 30 (11.8%) cases respectively. Transplantant did not function in 4 (1.57%) patients. RESULTS The probability of infection is highest in the early postoperative period. Risk factors were inadequate and prolonged antibiotic therapy, unrecognized infection postoperatively. The main problem in renal transplant recipients is urinary tract infection (90% of patients).
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Affiliation(s)
- E P Volynchik
- B.V. Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - N S Bogomolova
- B.V. Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - V A Goryainov
- B.V. Petrovsky Russian Research Center of Surgery, Moscow, Russia
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12
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Meije Y, Piersimoni C, Torre-Cisneros J, Dilektasli AG, Aguado JM. Mycobacterial infections in solid organ transplant recipients. Clin Microbiol Infect 2015; 20 Suppl 7:89-101. [PMID: 24707957 DOI: 10.1111/1469-0691.12641] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 03/21/2014] [Accepted: 03/29/2014] [Indexed: 12/29/2022]
Abstract
Mycobacterial infections represent a growing challenge for solid organ transplant recipients (SOT). The adverse effects of tuberculosis (TB) therapy present a major difficulty, due to the interactions with immunosuppressive drugs and direct drug toxicity. While TB may be donor-transmitted or community-acquired, it usually develops at a latent infection site in the recipient. Pre-transplant prevention efforts will improve transplant outcomes and avoid the complications associated with post-transplant diagnosis and treatment. The present review and consensus manuscript is based on the updated published information and expert recommendations. The current data about epidemiology, diagnosis, new regimens for the treatment of latent TB infection (LTBI), the experience with rifamycins for the treatment of active TB in the post-transplant period and the experience with isoniazid for LTBI in the liver transplant population, are also reviewed. We attempt to provide useful recommendations for each transplant period and problem concerning mycobacterial infections in SOT recipients.
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Affiliation(s)
- Y Meije
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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13
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Liu J, Yan J, Wan Q, Ye Q, Huang Y. The risk factors for tuberculosis in liver or kidney transplant recipients. BMC Infect Dis 2014; 14:387. [PMID: 25015108 PMCID: PMC4227141 DOI: 10.1186/1471-2334-14-387] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 07/03/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Liver or kidney transplant recipients are at a higher risk of developing tuberculosis (TB) than general population. We aimed to clarify the incidence density of and risk factors for TB in liver or kidney transplant recipients in the present study. METHODS All patients with TB following liver or kidney transplantation were investigated retrospectively at the Third Xiangya Hospital, Central South University, Changsha, China. The incidence density of TB was calculated. We performed a nested case-control study (1:1) to investigate by univariate and multivariate logistic regression analysis the potential risk factors for TB. RESULTS From January 2000 to August 2013, 1748 kidney and 166 liver transplant recipients were performed at a university teaching hospital. Among the 1914 recipients, 45 cases (2.4%) of TB were reported. The incidence density was 506 cases per 105 patient-years in kidney or liver transplant recipients, which was 7 times higher than in the general Chinese population (around 70 cases per 105 person-years). The median time to develop TB was 20.0 months (interquartile ratio: 5.0-70.0). The receipt of a graft from a cadaveric donor (odds ratio [OR] = 3.7; 95% confidence interval [CI] = 1.4-10.0; P = 0.010) and the preoperative evidence of latent TB (OR = 6.8; 95% CI = 2.0-22.7; P = 0.002) were identified as two risk factors for developing TB in liver or kidney transplant recipients. CONCLUSIONS The incidence density of TB among liver or kidney transplant recipients was much higher than in the general Chinese population. Recipients receiving a graft from a cadaveric donor and the preoperative evidence of latent TB were two major risk factors for developing TB in liver or kidney transplant recipients.
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Affiliation(s)
| | | | - Qiquan Wan
- Department of Transplant Surgery, The Third Xiangya Hospital, Central South University, Changsha 410013, China.
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14
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Mycobacterium tuberculosis infection following kidney transplantation. BIOMED RESEARCH INTERNATIONAL 2013; 2013:347103. [PMID: 24222903 PMCID: PMC3816022 DOI: 10.1155/2013/347103] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 06/19/2013] [Indexed: 11/20/2022]
Abstract
Introduction and Aims. Post-transplant tuberculosis (TB) is a problem in successful long-term outcome of renal transplantation recipients. Our objective was to describe the pattern and risk factors of TB infection and the prognosis in our transplant recipients. Patients and Methods. This study was a retrospective review of the records of 491 renal transplant recipients in our hospital during the period from January 1986 to December 2009. The demographic data, transplant characteristics, clinical manifestations, diagnostic criteria, treatment protocol, and long-term outcome of this cohort of patients were analyzed. Results. 16 patients (3,2%) developed post-transplant TB with a mean age of 32,5 ± 12,7 (range: 13–60) years and a mean post-transplant period of 36,6months (range: 12,3 months–15,9 years). The forms of the diseases were pulmonary in 10/16 (62,6%), disseminated in 3/16 (18,7%), and extrapulmonary in 3/16 (18,7%). Graft dysfunction was observed in 7 cases (43,7%) with tissue-proof acute rejection in 3 cases and loss of the graft in 4 cases. Hepatotoxicity developed in 3 patients (18,7%) during treatment. Recurrences were observed in 4 cases after early stop of treatment. Two patients (12.5%) died. Conclusion. Extra pulmonary and disseminated tuberculosis were observed in third of our patients. More than 9months of treatment may be necessary to prevent recurrence.
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Marques IDB, Azevedo LS, Pierrotti LC, Caires RA, Sato VAH, Carmo LPF, Ferreira GF, Gamba C, de Paula FJ, Nahas WC, David-Neto E. Clinical features and outcomes of tuberculosis in kidney transplant recipients in Brazil: a report of the last decade. Clin Transplant 2013; 27:E169-76. [DOI: 10.1111/ctr.12077] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2012] [Indexed: 02/04/2023]
Affiliation(s)
- Igor D. B. Marques
- Renal Transplant Service; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo; Brazil
| | - Luiz S. Azevedo
- Renal Transplant Service; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo; Brazil
| | - Lígia C. Pierrotti
- Department of Infectious Diseases; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo; Brazil
| | - Renato A. Caires
- Division of Nephrology; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo; Brazil
| | - Víctor A. H. Sato
- Division of Nephrology; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo; Brazil
| | - Lilian P. F. Carmo
- Renal Transplant Service; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo; Brazil
| | - Gustavo F. Ferreira
- Renal Transplant Service; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo; Brazil
| | - Cristiano Gamba
- Department of Infectious Diseases; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo; Brazil
| | - Flávio J. de Paula
- Renal Transplant Service; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo; Brazil
| | - William C. Nahas
- Renal Transplant Service; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo; Brazil
| | - Elias David-Neto
- Renal Transplant Service; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo; Brazil
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16
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17
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Fraisse P. Traitement des infections tuberculeuses latentes. Rev Mal Respir 2012; 29:579-600. [DOI: 10.1016/j.rmr.2011.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Accepted: 07/26/2011] [Indexed: 11/24/2022]
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18
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Ersan S, Celik A, Atila K, Aykut Sifil A, Cavdar C, Soylu A, Bora S, Gulay H, Camsari T. Tuberculosis in Renal Transplant Recipients. Ren Fail 2011; 33:753-7. [DOI: 10.3109/0886022x.2011.599095] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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19
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Abstract
BACKGROUND Tuberculosis (TB) remains a leading cause of death in endemic countries and is 20 to 70 times more common in renal transplant recipients, where it contributes to both increased morbidity and mortality. This review will focus on the epidemiology of TB in renal transplant recipients and critically appraise the published literature on isoniazid prophylaxis in renal transplantation. METHODS A literature search for randomized and nonrandomized studies investigating the use of isoniazid prophylaxis in renal transplant recipients was conducted using Ovid MEDLINE, the Cochrane Library, the Transplant Library, and EMBASE. Relative risks (RRs) with 95% confidence intervals (CIs) are reported. Meta-analysis of the randomized controlled trials (RCTs) was performed with a fixed-effects model. RESULTS Eleven relevant studies were identified; six nonrandomized and five RCTs. The nonrandomized studies indicate a reduced risk of TB with isoniazid prophylaxis. The RCTs demonstrated conflicting results, with two studies finding a reduction in TB with prophylaxis and two studies finding no difference. Meta-analysis of the 709 patients from the four RCTs demonstrated a reduced risk of TB with isoniazid prophylaxis (RR, 0.31; 95% CI, 0.19-0.51). No significant difference was found in the incidence of hepatitis (RR, 1.22; 95% CI, 0.91-1.65). CONCLUSION Both randomized and nonrandomized studies support the value of isoniazid as TB prophylaxis in renal transplant recipients at risk of active infection. Clinicians should consider prophylaxis in renal transplant recipients in endemic areas or in recipients in nonendemic countries who are at risk. However, the evidence for the benefit of isoniazid prophylaxis in renal transplantation is not robust and there is still a need for a large multicenter trial of isoniazid prophylaxis in kidney transplantation in an endemic area.
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20
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Fan MH, Hadjiliadis D. Incidence and management of mycobacterial infection in solid organ transplant recipients. Curr Infect Dis Rep 2010; 11:216-22. [PMID: 19366564 DOI: 10.1007/s11908-009-0032-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Although advances in surgical technique, immunosuppressive regimens, and medical management have led to improved survival and quality of life after solid organ transplantation, infection continues to represent a major cause of morbidity and mortality in transplant recipients. Immunosuppressive therapy after transplantation compromises cell-mediated immunity in particular, leaving the patient at risk for opportunistic as well as routine community-acquired infections. Mycobacterial infection is a rare but important complication of solid organ transplantation, presenting significant risk to the patient and challenges in terms of treatment. The available literature consists predominantly of case reports and institutional experiences. This article examines both Mycobacterium tuberculosis and nontuberculous mycobacterial infection in the transplant setting.
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Affiliation(s)
- Ming-Hui Fan
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania Medical Center, 835 West Gates Building, 3600 Spruce Street, Philadelphia, PA 19104, USA.
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21
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Affiliation(s)
- D Lopez de Castilla
- Department of Epidemiology and Environmental Health Sciences, Columbia University College of Physicians and Surgeons, Columbia University Medical Center, New York, New York 10032, USA
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22
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Kim MJ, Kim HR, Hwang SS, Kim YW, Han SK, Shim YS, Yim JJ. Prevalence and its predictors of extrapulmonary involvement in patients with pulmonary tuberculosis. J Korean Med Sci 2009; 24:237-41. [PMID: 19399264 PMCID: PMC2672122 DOI: 10.3346/jkms.2009.24.2.237] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2007] [Accepted: 06/24/2008] [Indexed: 11/20/2022] Open
Abstract
Extrapulmonary organ involvement in human immunodefiaency virus (HIV)-infected patients with pulmonary tuberculosis (TB) is reported to be 26%, however, the clinical predictors of extrapulmonary involvement in pulmonary TB patients has not been reported yet. We tried to determine the clinical predictors of presence of extrapulmonary involvement in patients with pulmonary TB. Cross-sectional study was performed including all adult patients with culture-proven pulmonary TB diagnosed between January 1, 2004 and July 30, 2006, at a tertiary referral hospital in South Korea. The presence of extra-pulmonary TB involvement was diagnosed based on bacteriological, pathological, or clinical evidence. Among 320 patients with a culture-proven pulmonary TB, 40 had extrapulmonary involvement. Patients with bilateral lung involvement were more likely to have extrapulmonary involvement, with an adjusted odds ratio (OR) of 4.21 (95% confidence interval [CI], 1.82-9.72), while patients older than 60 yr (adjusted OR, 0.27; 95% CI, 0.08-0.89), patients with cavitary lesions (adjusted OR, 0.37; 95% CI, 0.16-0.84), and with higher levels of serum albumin (adjusted OR, 0.45; 95% CI, 0.25-0.78) had less frequent involvement. Clinicians should be aware of the possibility of extrapulmonary involvement in TB patients with bilateral lung involvement without cavity formation or lower levels of serum albumin.
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Affiliation(s)
- Min Jae Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hye-Ryoun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Sik Hwang
- Department of Social and Preventive Medicine, College of Medicine, Inha University, Incheon, Korea
| | - Young Whan Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Koo Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Young-Soo Shim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul, Korea
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Guida J, Bignotto Rosane D, Urbini-Santos C, Alves-Filho G, Ribeiro Resende M, Mazzali M. Tuberculosis in Renal Transplant Recipients: A Brazilian Center Registry. Transplant Proc 2009; 41:883-4. [DOI: 10.1016/j.transproceed.2009.01.075] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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24
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Lioté H. Tuberculose, agents anti-TNF et autres immunosuppresseurs : évolution des stratégies de prévention. Rev Mal Respir 2008; 25:1237-49. [DOI: 10.1016/s0761-8425(08)75089-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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25
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Kang GCW, Yam A, Lee JYL. A Tuberculous Midpalmar Abscess of the Hand Due to Reactivation of Previous Pulmonary Tuberculosis. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2008. [DOI: 10.47102/annals-acadmedsg.v37n11p982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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26
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Chen SY, Wang CX, Chen LZ, Fei JG, Deng SX, Qiu J, Li J, Chen GO, Fu HM, Xie CM. Tuberculosis in southern Chinese renal-transplant recipients. Clin Transplant 2008; 22:780-4. [DOI: 10.1111/j.1399-0012.2008.00878.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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27
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Ruangkanchanasetr P, Natejumnong C, Kitpanich S, Chaiprasert A, Luesutthiviboon L, Supaporn T. Prevalence and Manifestations of Tuberculosis in Renal Transplant Recipients: A Single-Center Experience in Thailand. Transplant Proc 2008; 40:2380-1. [DOI: 10.1016/j.transproceed.2008.06.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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28
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Torres J, Aguado JM, San Juan R, Andrés A, Sierra P, López-Medrano F, Morales JM. Hepatitis C virus, an important risk factor for tuberculosis in immunocompromised: experience with kidney transplantation. Transpl Int 2008; 21:873-8. [PMID: 18482173 DOI: 10.1111/j.1432-2277.2008.00694.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Little is known about the role of hepatitis C virus (HCV) infection in the development of tuberculosis (TB) in patients with immunosuppression. We performed a retrospective case-control study (1:4) to investigate by univariate and multivariate logistic regression analysis the importance of HCV infection in the development of TB in a cohort of kidney transplant recipients (KTR). TB was diagnosed in 16 out of 2012 (0.8%) KTR between 1976 and 2004. The percentage of HCV-positive patients was significantly higher in cases than in controls (56.3% vs. 18.8%; P=0.02). By multivariate analysis, the only two independent risk factors associated with the development of TB were the presence of HCV infection (P=0.003; OR=6.5; 95% CI 1.9-23) and serum creatinine over 1.5 mg/dl (P=0.03; OR=4.8; 95% CI 1.1-21). HCV infection and chronic graft dysfunction are important risks factors for TB in KTR.
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Affiliation(s)
- Juan Torres
- Unit of Infectious Diseases and Renal Transplantation, Department of Nephrology, University Hospital 12 de Octubre, Madrid, Spain
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29
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Bofinger JJ, Schlossberg D. Fever of unknown origin caused by tuberculosis. Infect Dis Clin North Am 2008; 21:947-62, viii. [PMID: 18061084 DOI: 10.1016/j.idc.2007.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Tuberculosis is an important cause of fever of unknown origin. Travel, age, dialysis, diabetes, birth in a country with a high prevalence of tuberculosis, and immunoincompetence are among the most salient risks. Associated physical findings, radiologic evaluation, and hematologic and endocrinologic abnormalities may provide clues to the diagnosis. Both noninvasive and invasive diagnostic modalities are reviewed. Because diagnosis may be elusive, therapeutic and diagnostic trials of antituberculous therapy should be considered in all patients with fever of unknown origin who defy diagnosis.
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Affiliation(s)
- Jason J Bofinger
- Section of Infectious Diseases, Temple University Hospital, Parkinson Pavilion, Philadelphia, PA 19140, USA
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30
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Nayak S, Satish R. Genitourinary tuberculosis after renal transplantation-a report of three cases with a good clinical outcome. Am J Transplant 2007; 7:1862-4. [PMID: 17524075 DOI: 10.1111/j.1600-6143.2007.01853.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Tuberculosis (TB) continues to be a major opportunistic infection after renal transplantation especially in the tropical countries. The risk of TB in renal transplant recipients is reported to be 20-74 times higher than that in the general population. Genitourinary TB that occurs after renal transplantation in uncommon and appears to present differently than genitourinary TB in the non-transplant population. An increased risk of graft rejection and graft loss has been reported. We report three cases of genitourinary TB in renal transplant recipients, all of whom had a good clinical outcome and a review of published literature.
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Affiliation(s)
- S Nayak
- St John's Medical College Hospital - Nephrology Sarjapur Raod, Koramangala, Bangalore, Karnataka 560034, India.
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