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Elalouf A. Infections after organ transplantation and immune response. Transpl Immunol 2023; 77:101798. [PMID: 36731780 DOI: 10.1016/j.trim.2023.101798] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 01/08/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023]
Abstract
Organ transplantation has provided another chance of survival for end-stage organ failure patients. Yet, transplant rejection is still a main challenging factor. Immunosuppressive drugs have been used to avoid rejection and suppress the immune response against allografts. Thus, immunosuppressants increase the risk of infection in immunocompromised organ transplant recipients. The infection risk reflects the relationship between the nature and severity of immunosuppression and infectious diseases. Furthermore, immunosuppressants show an immunological impact on the genetics of innate and adaptive immune responses. This effect usually reactivates the post-transplant infection in the donor and recipient tissues since T-cell activation has a substantial role in allograft rejection. Meanwhile, different infections have been found to activate the T-cells into CD4+ helper T-cell subset and CD8+ cytotoxic T-lymphocyte that affect the infection and the allograft. Therefore, the best management and preventive strategies of immunosuppression, antimicrobial prophylaxis, and intensive medical care are required for successful organ transplantation. This review addresses the activation of immune responses against different infections in immunocompromised individuals after organ transplantation.
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Affiliation(s)
- Amir Elalouf
- Bar-Ilan University, Department of Management, Ramat Gan 5290002, Israel.
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2
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Rashid HU, Begum NAS, Kashem TS. Mycobacterial infections in solid organ transplant recipients. KOREAN JOURNAL OF TRANSPLANTATION 2021; 35:208-217. [PMID: 35769848 PMCID: PMC9235462 DOI: 10.4285/kjt.21.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 12/25/2021] [Indexed: 11/25/2022] Open
Abstract
Mycobacterium tuberculosis (MTB) infection in solid organ transplant (SOT) recipients remains a major challenge for physicians and surgeons. Active tuberculosis (TB) is associated with increased morbidity and mortality in SOT recipients. MTB usually develops after transplantation in a recipient with latent TB infection (LTBI) before transplantation and may also be transmitted from the donor or acquired from the community. Therefore, screening for LTBI in donors and recipients before transplantation is very important in preventing active disease after transplantation. This review article is based on recently published data, case series, and expert recommendations. We reviewed updated information about the epidemiology, diagnosis, and treatment of latent and active TB before and after transplantation. We also reviewed recent treatments for multidrug-resistant TB.
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Affiliation(s)
- Harun Ur Rashid
- Department of Nephrology, Kidney Foundation Hospital and Research Institute, Dhaka, Bangladesh
| | - Nura Afza Salma Begum
- Department of Nephrology, Kidney Foundation Hospital and Research Institute, Dhaka, Bangladesh
| | - Tasnuva Sarah Kashem
- Department of Nephrology, Kidney Foundation Hospital and Research Institute, Dhaka, Bangladesh
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Thitisuriyarax S, Vanichanan J, Udomkarnjananun S, Townamchai N, Jutivorakool K. Risk factors and clinical outcomes of tuberculosis among kidney transplant recipients in high endemic country. Transpl Infect Dis 2021; 23:e13566. [PMID: 33428318 DOI: 10.1111/tid.13566] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/08/2020] [Accepted: 12/29/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Tuberculosis (TB) is considered as a challenge issue in solid organ transplant recipients because of high morbidity and mortality. Active TB after transplant mostly occurs from reactivation of latent infection. Understanding risk factors and clinical information of TB may provide an appropriate prevention and treatment strategies in this specific patient population, however data from high endemic area is scarce. METHODS A matched single-center, case-control study was conducted in our institute. Cases were defined as newly diagnosed confirmed or clinical active TB in patients who underwent kidney transplant (KT) between April 1992 and October 2018. For each case, 5 controls were matched by age and sex. Risk factor associated with TB was determined using univariate and multivariate conditional logistic regression. RESULTS Between study period, KT was performed in 787 patients. Twenty-seven patients (3.43%) were diagnosed with active TB including 20 confirmed and 7 clinical diagnosed cases. The global incidence of TB in our population was 315 cases per 100 000 patients per year. Among 27 cases, pulmonary involvement was the most common (48.1%) followed by disseminated (18.5%), extrapulmonary (14.8%), pleura (11.1%) and pleuropulmonary (7.4%) TB. Allograft rejection was significantly associated with active TB (P < .001). The median onset duration of infection was 17 months (IQR, 4-59 months) after KT. Twenty-four (88.9%) patients received rifampicin containing regimen for treatment with median duration of 10 months (IQR, 6-12 months). All patients were cured after complete treatment, however those with TB remained having unfavorable outcomes including higher all-cause mortality and graft loss. CONCLUSIONS Incidence rate of TB in KT recipients is higher than normal population. Allograft rejection was identified as a significant risk factor. Increase unfavorable outcomes including graft loss and mortality were also observed among patients with TB.
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Affiliation(s)
- Saranya Thitisuriyarax
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Jakapat Vanichanan
- Division of Infectious Diseases, Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Natavudh Townamchai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kamonwan Jutivorakool
- Division of Infectious Diseases, Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Gupta KL, Bagai S, Kumar H, Nayak S, Muthu V, Kumar V, Rathi M, Kohli HS, Sharma A, Ramachandran R. Levofloxacin based non-rifampicin anti-tuberculous therapy: An effective alternative in renal transplant recipients in resource limited setting. Nephrology (Carlton) 2020; 26:178-184. [PMID: 33155329 DOI: 10.1111/nep.13816] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 09/27/2020] [Accepted: 11/01/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Rifampicin is one of the most effective components of anti-tuberculous therapy (ATT). Since rifampicin is a hepatic enzyme (CYP3A4) inducer, in a post-renal transplant recipient, the dose of calcineurin inhibitors needs to be up-regulated and frequently monitored. In resource-limited (low- and lower-middle-income countries) setting this is not always feasible. Therefore, we evaluated a non-rifampicin-based ATT using levofloxacin in kidney transplant recipients. METHODS We retrospectively studied the medical records of renal transplant recipients diagnosed with tuberculosis in our institute between 2014 and 2017. After a brief discussion with patients regarding the nature and course of ATT, those who opted for a non-rifampicin based therapy due to financial constraints were included in the study and followed for a minimum of 6 months period after the completion of ATT. RESULTS Out of the 550 renal transplant recipients, 67 (12.2%) developed tuberculosis after a median period of 24 (1-228) months following transplantation, of them, 64 patients opted for non-rifampicin-based ATT. The mean age was 37.6 years. Only 25% were given anti-thymocyte globulin based induction, while the majority (56; 87.5%) of them were on tacrolimus-based triple-drug maintenance therapy. Extrapulmonary tuberculosis was noted in 33% of cases, while 12 (18.7%) had disseminated disease. The median duration of treatment was 12 months and the cure rate of 93.7% (n = 60) was achieved at the end of therapy. CONCLUSION Levofloxacin based ATT appears to be a safe and effective alternative of rifampicin in kidney transplant recipients who cannot afford heightened tacrolimus dosage.
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Affiliation(s)
- Krishan Lal Gupta
- Department of Nephrology and Renal Transplantation, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahil Bagai
- Department of Nephrology and Renal Transplantation, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harsha Kumar
- Department of Nephrology and Renal Transplantation, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Saurabh Nayak
- Department of Nephrology and Renal Transplantation, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivek Kumar
- Department of Nephrology and Renal Transplantation, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology and Renal Transplantation, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harbir S Kohli
- Department of Nephrology and Renal Transplantation, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Sharma
- Department of Renal Transplant Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Department of Nephrology and Renal Transplantation, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Subramanian AK, Theodoropoulos NM. Mycobacterium tuberculosis infections in solid organ transplantation: Guidelines from the infectious diseases community of practice of the American Society of Transplantation. Clin Transplant 2019; 33:e13513. [PMID: 30817030 DOI: 10.1111/ctr.13513] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/12/2019] [Indexed: 02/06/2023]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of tuberculosis in the pre- and post-transplant period. The challenges of screening for both latent and active TB in the setting of transplantation are reviewed. The use of interferon gamma release assays for detection of latent tuberculosis is discussed and compared to tuberculin skin testing. Given the limitations of both testing modality, it is important to consider exposure history and chest imaging. The clinical manifestations of active tuberculosis in transplantation are covered. New recommendations for treatment of latent tuberculosis and active tuberculosis are included.
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Affiliation(s)
- Aruna K Subramanian
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California
| | - Nicole M Theodoropoulos
- Division of Infectious Diseases & Immunology, University of Massachusetts Medical School, Worcester, Massachusetts
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Kumar S, Minz M, Sinha SK, Vaiphei K, Sharma A, Singh S, Kenwar DB. Esophageal tuberculosis with coexisting opportunistic infections in a renal allograft transplant recipient. Transpl Infect Dis 2016; 19. [PMID: 27885762 DOI: 10.1111/tid.12640] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 05/11/2016] [Accepted: 08/29/2016] [Indexed: 11/30/2022]
Abstract
We report a renal allograft transplant recipient with esophageal tuberculosis (TB) coinfected with herpes simplex virus (HSV) and Candida. The patient presented with oropharyngeal candidiasis and was started on fluconazole. Upper gastrointestinal endoscopy showed whitish patches with mucosal ulcers in the esophagus. Histopathological examination confirmed TB and HSV infection. The patient recovered after antiviral, antifungal, and anti-tubercular therapy with reduction in immunosuppression. In a TB-endemic zone, TB can coexist with opportunistic infections in an immunocompromised host.
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Affiliation(s)
- Sunil Kumar
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mukut Minz
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Saroj K Sinha
- Department of Gastroenterology, PGIMER, Chandigarh, India
| | - Kim Vaiphei
- Department of Histopathology, PGIMER, Chandigarh, India
| | - Ashish Sharma
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sarbpreet Singh
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Deepesh B Kenwar
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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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: 72] [Impact Index Per Article: 8.0] [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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Chen YJ, Wu CY, Shen JL, Chen TT, Chang YT. Association between traditional systemic antipsoriatic drugs and tuberculosis risk in patients with psoriasis with or without psoriatic arthritis: Results of a nationwide cohort study from Taiwan. J Am Acad Dermatol 2013; 69:25-33. [DOI: 10.1016/j.jaad.2012.12.966] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 12/08/2012] [Accepted: 12/18/2012] [Indexed: 12/17/2022]
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Subramanian AK, Morris MI. Mycobacterium tuberculosis infections in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:68-76. [PMID: 23465000 DOI: 10.1111/ajt.12100] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- A K Subramanian
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Abstract
Infections are a major cause of morbidity and mortality in kidney transplant recipients. To some extent, these may be preventable. Careful pretransplant screening, immunization, and post-transplant prophylactic antimicrobials may all reduce the risk for post-transplant infection. However, because transplant recipients may not manifest typical signs and symptoms of infection, diagnoses may be confounded. Furthermore, treatment regimens may be complicated by drug interactions and the need to maintain immunosuppression to avoid allograft rejection. This article reviews common post-transplant infections, including prophylactic, diagnostic, and treatment strategies, providing guidance regarding care of kidney transplant patients with infection.
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Affiliation(s)
- Shamila Karuthu
- Division of Nephrology, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Ryan C, Amor KT, Menter A. The use of cyclosporine in dermatology: part II. J Am Acad Dermatol 2010; 63:949-72; quiz 973-4. [PMID: 21093660 DOI: 10.1016/j.jaad.2010.02.062] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 02/01/2010] [Accepted: 02/08/2010] [Indexed: 01/11/2023]
Abstract
UNLABELLED Cyclosporine is highly effective in the treatment of a multitude of dermatoses. Concern over its side effect profile has limited its use in dermatology. Adverse effects are, for the most part, dose dependent and related to duration of therapy. Using the recommended monitoring protocols results in a significant decrease in the incidence of cyclosporine-related toxicities. This article provides a comprehensive review of the pharmacokinetics of cyclosporine, potential drug interactions, adverse effects, and recommendations for monitoring in patients treated with cyclosporine. The use of cyclosporine in pregnancy and in the pediatric population is also addressed. LEARNING OBJECTIVES After completing this learning activity, participants should be familiar with the monitoring guidelines of cyclosporine, its contraindications, its possible drug interactions, its adverse effect profile, and its use in pregnancy and the childhood and adolescent populations.
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Affiliation(s)
- Caitriona Ryan
- Department of Dermatology at Baylor University Medical Center, Dallas, Texas 75246, USA
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Song CS, Kim H, Shim CN, Yoon MY, Seo MH, Park W, Lee JE, Hur SE, Lee KB. A Case of Tuberculous Peritonitis Confirmed by Laparoscopic Biopsy in a Patient Receiving Maintenance Hemodialysis Patient after Renal Transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2010. [DOI: 10.4285/jkstn.2010.24.1.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Chang Seok Song
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyang Kim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Choong Nam Shim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Yong Yoon
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Hye Seo
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wan Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Eun Lee
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Eun Hur
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Beck Lee
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.
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Khaira A, Bagchi S, Sharma A, Mukund A, Mahajan S, Bhowmik D, Dinda AK, Agarwal SK. Renal allograft tuberculosis: report of three cases and review of literature. Clin Exp Nephrol 2009; 13:392-396. [DOI: 10.1007/s10157-009-0158-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Accepted: 12/26/2008] [Indexed: 11/24/2022]
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Lebwohl M, Bagel J, Gelfand JM, Gladman D, Gordon KB, Hsu S, Kalb RE, Kimball AB, Korman NJ, Krueger GG, Mease P, Morison WL, Paller A, Pariser DM, Ritchlin C, Strober B, Van Voorhees A, Weinstein GD, Young M, Horn L. From the Medical Board of the National Psoriasis Foundation: Monitoring and vaccinations in patients treated with biologics for psoriasis. J Am Acad Dermatol 2008; 58:94-105. [DOI: 10.1016/j.jaad.2007.08.030] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Revised: 08/14/2007] [Accepted: 08/28/2007] [Indexed: 02/07/2023]
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Jung H, Oh YM, Lee SD, Kim WS, Kim DS, Kim WD, Kim JJ, Lee SG, Shim TS. Clinical Characteristics of Tuberculosis in Liver or Heart Transplant Recipients. Tuberc Respir Dis (Seoul) 2006. [DOI: 10.4046/trd.2006.61.5.440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Hoon Jung
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon-Mok Oh
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Do Lee
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo Sung Kim
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Soon Kim
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Dong Kim
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Joong Kim
- Division of Cardiology, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Gyu Lee
- Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Asan Medical Center, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Tae Sun Shim
- Division of Pulmonary and Critical Care Medicine, Asan Medical Center, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
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