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Lee YW, Chung H, Kim SH, Sung H, Ha SM, Jwa EK, Jung DH, Moon DB, Lee SG, Lee SO. Safety and outcome of treatment of latent tuberculosis infection in liver transplant recipients. Infection 2024; 52:1055-1061. [PMID: 38347366 DOI: 10.1007/s15010-023-02161-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/14/2023] [Indexed: 06/02/2024]
Abstract
PURPOSE Liver transplant (LT) recipients have an increased risk of tuberculosis (TB), which is associated with higher mortality rates. This retrospective cohort study assessed the outcome and tolerability of screening and treatment of latent tuberculosis infection (LTBI) in LT recipients. METHODS Between March 2020 and February 2022, all adult LT candidates at our institution were screened for LTBI. The candidates who tested positive for interferon-γ-releasing assay or met epidemiological or clinical-radiological criteria for LTBI were treated and monitored. RESULTS Among the 857 LT recipients, 199 (23.2%) were diagnosed with LTBI, of which 171 (85.9%) initiated LTBI treatment. The median duration of follow-up was 677 days. Adequate LTBI treatment occurred in 141/171 (82.5%) patients and was discontinued prematurely in 30/171 (17.5%) patients. The most common reason for discontinuation was liver enzyme elevation (11/30, 36.7%), although only five discontinued treatment due to suspicion of isoniazid-associated hepatotoxicity. None of the LTBI-treated patients developed active TB during the follow-up period, while 3.6% (1/28) of untreated LTBI patients and 0.6% (4/658) of patients without LTBI developed TB. CONCLUSION These findings demonstrate that LTBI screening and treatment is a safe and effective strategy to prevent TB in LT recipients. However, monitoring for adverse events and liver enzyme elevation is recommended.
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Affiliation(s)
- Yun Woo Lee
- Division of Infectious Diseases, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Hyemin Chung
- Division of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Su-Min Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eun-Kyoung Jwa
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Hwan Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Deok-Bog Moon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Gyu Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Katrak S, Han E, Readhead A, Fung M, Keh C, Flood J, Barry P. Solid organ transplant recipients with tuberculosis disease in California, 2010 to 2020. Am J Transplant 2023; 23:401-407. [PMID: 36695700 DOI: 10.1016/j.ajt.2022.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 11/07/2022] [Accepted: 11/29/2022] [Indexed: 01/13/2023]
Abstract
Using California Tuberculosis (TB) Registry data from 2010-2020, we compared the presentation and outcomes of patients with TB aged >15 years with and without solid organ transplantation (SOT). We matched to the United Network for Organ Sharing registry for 1987-2020 and the estimated time from transplantation to the diagnosis of TB, the incidence of posttransplant TB, and the probability of death and graft failure in SOT recipients with TB, compared to those without TB. From 2010-2020, there were 148 posttransplant TB cases. Patients with posttransplant TB were more likely to have extrapulmonary disease and more than twice as likely to die as TB patients without SOT (relative risk [RR], 2.2; 95% confidence interval [CI], 1.6-2.9). The median time from transplantation to TB diagnosis was 1.2 years, with the shortest time among lung transplant recipients. The incidence of TB disease among Californians with SOT was 56.0 per 100 000 person-years. The risk of death was higher among SOT recipients with posttransplant TB than those without (adjusted hazard ratio, 2.8; 95% CI, 2.0-4.1); the risk of graft failure was higher among kidney transplant recipients with posttransplant TB than those without (adjusted hazard ratio, 3.4; 95% CI, 1.7-6.9). An increased risk of death and graft failure in SOT recipients with posttransplant TB highlights the need for enhanced pretransplant TB prevention.
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Affiliation(s)
- Shereen Katrak
- Tuberculosis Control Branch, California Department of Public Health, Richmond, California, USA; Division of Infectious Diseases, University of California, San Francisco, California, USA.
| | - Emily Han
- Tuberculosis Control Branch, California Department of Public Health, Richmond, California, USA
| | - Adam Readhead
- Tuberculosis Control Branch, California Department of Public Health, Richmond, California, USA
| | - Monica Fung
- Division of Infectious Diseases, University of California, San Francisco, California, USA
| | - Chris Keh
- Tuberculosis Control Branch, California Department of Public Health, Richmond, California, USA; Division of Infectious Diseases, University of California, San Francisco, California, USA
| | - Jennifer Flood
- Tuberculosis Control Branch, California Department of Public Health, Richmond, California, USA
| | - Pennan Barry
- Tuberculosis Control Branch, California Department of Public Health, Richmond, California, USA; Division of Infectious Diseases, University of California, San Francisco, California, USA
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Ying C, He C, Xu K, Li Y, Zhang Y, Wu W. Progress on diagnosis and treatment of latent tuberculosis infection. Zhejiang Da Xue Xue Bao Yi Xue Ban 2022; 51:691-696. [PMID: 36915977 PMCID: PMC10262000 DOI: 10.3724/zdxbyxb-2022-0445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/20/2022] [Indexed: 12/24/2022]
Abstract
One fourth of the global population has been infected with Mycobacterium tuberculosis, and about 5%-10% of the infected individuals with latent tuberculosis infection (LTBI) will convert to active tuberculosis (ATB). Correct diagnosis and treatment of LTBI are important in ending the tuberculosis epidemic. Current methods for diagnosing LTBI, such as tuberculin skin test (TST) and interferon-γ release assay (IGRA), have limitations. Some novel biomarkers, such as transcriptome derived host genes in peripheral blood cells, will help to distinguish LTBI from ATB. More emphasis should be placed on surveillance in high-risk groups, including patients with HIV infection, those using biological agents, organ transplant recipients and those in close contact with ATB patients. For those with LTBI, treatment should be based on the risk of progression to ATB and the potential benefit. Prophylactic LTBI regimens include isoniazid monotherapy for 6 or 9 months, rifampicin monotherapy for 4 months, weekly rifapentine plus isoniazid for 3 months (3HP regimen) and daily rifampicin plus isoniazid for 3 months (3HR regimen). The success of the one month rifapentine plus isoniazid daily regimen (1HP regimen) suggests the feasibility of an ultra-short treatment strategy although its efficacy needs further assessment. Prophylactic treatment of LTBI in close contact with MDR-TB patients is another challenge, and the regimens include new anti-tuberculosis drugs such as bedaquiline, delamanid, fluoroquinolone and their combinations, which should be carefully evaluated. This article summarizes the current status of diagnosis and treatment of LTBI and its future development direction.
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Affiliation(s)
- Chiqing Ying
- 1. The First Affiliated Hospital, Zhejiang University School of Medicine, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou 310003, China
| | - Chang He
- 1. The First Affiliated Hospital, Zhejiang University School of Medicine, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou 310003, China
| | - Kaijin Xu
- 1. The First Affiliated Hospital, Zhejiang University School of Medicine, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou 310003, China
| | - Yongtao Li
- 1. The First Affiliated Hospital, Zhejiang University School of Medicine, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou 310003, China
| | - Ying Zhang
- 1. The First Affiliated Hospital, Zhejiang University School of Medicine, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou 310003, China
- 2. Jinan Microecological Biomedicine Shandong Laboratory, Jinan 250117, China
| | - Wei Wu
- 1. The First Affiliated Hospital, Zhejiang University School of Medicine, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou 310003, China
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Ali M, Dosani D, Corbett R, Johansson L, Charif R, Kon OM, Duncan N, Ashby D. Diagnosis of tuberculosis in dialysis and kidney transplant patients. Hemodial Int 2022; 26:361-368. [PMID: 35393765 PMCID: PMC9546140 DOI: 10.1111/hdi.13010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 02/14/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES In patients with chronic kidney disease the risk of developing Tuberculosis is increased, while the presentation is often atypical making the diagnosis more difficult. The aim of this study is to describe the presentation of Tuberculosis in dialysis and kidney transplant patients, including the range of diagnostic approaches and the utility of different sample types. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS In this retrospective study, case records of dialysis and kidney transplant patients were reviewed, including all those treated for Tuberculosis between January 2009 and December 2020. RESULTS Over 12 years, there were 143 cases of Tuberculosis in 141 patients (aged 17-86, 50.4% male). Tuberculosis was most common in Asian patients (64%) and those receiving hemodialysis (82%), particularly during the first year after dialysis initiation (54% of dialysis cases). Non-pleural/pulmonary disease accounted 40% of cases, and non-organ-specific presenting features were prominent including fever, lymphadenopathy, and weight loss. The diagnosis was confirmed microbiologically or histologically in 87 cases (61%), with low sensitivity observed for many types of samples including sputum (18%) and pleural fluid (12%). Higher sensitivity was observed with tissue samples including bronchoscopic lymph node aspiration (75%) and other lymph node sampling (92%). In the 52 cases where drug sensitivities were available, resistance to a first line treatment, most commonly isoniazid, was seen in 12 cases (23%). Furthermore, 1- and 5-year survival from diagnosis were 78% and 61%, respectively. Baseline variables independently associated with poorer survival were age (OR 1.8 per decade, 95% CI 1.4-2.3), weight loss over 10% (OR 1.9, 95% CI 1.0-3.5), and a non-confirmed diagnosis (OR 1.6, 95% CI 1.2-2.1). CONCLUSIONS Tuberculosis is common in dialysis and kidney transplant patients, particularly during the first year of dialysis. Short-term mortality is high, but the diagnostic sensitivity of many types of samples is low, so that diagnosis is difficult, with treatment often initiated without confirmation. These data highlight the importance of judgment and clinical experience with this complex patient group.
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Affiliation(s)
- Mahrukh Ali
- West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Dhriti Dosani
- West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Richard Corbett
- West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Lina Johansson
- West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Rawya Charif
- West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Onn Min Kon
- Chest and Allergy Clinic, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Neill Duncan
- West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Damien Ashby
- West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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Varughese S, Sahay M, Shah D, Nagvekar V, Jha V. Evaluation and management of tuberculosis in solid organ transplant recipients: South Asian expert group opinion. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_18_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Zeng QZ, Zhang YY, Wu YJ, Zhang ZY, Zhang JN, Fu HX, Wang JZ, Wang FR, Yan CH, Mo XD, Wang Y, Chen YH, Chang YJ, Xu LP, Liu KY, Huang XJ, Zhang XH. Frequency, Risk Factors, and Outcome of Active Tuberculosis following Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2020; 26:1203-1209. [DOI: 10.1016/j.bbmt.2020.02.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/15/2020] [Accepted: 02/16/2020] [Indexed: 12/16/2022]
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Yang A, Shi J, Luo Y, Ye Y, Tan Y, Huang H, Zhao Y. Allo-HSCT recipients with invasive fungal disease and ongoing immunosuppression have a high risk for developing tuberculosis. Sci Rep 2019; 9:20402. [PMID: 31892702 PMCID: PMC6938515 DOI: 10.1038/s41598-019-56013-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 12/05/2019] [Indexed: 12/24/2022] Open
Abstract
Patients underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) are at high risk of acquiring tuberculosis (TB) due to a status of immunosuppression. We conducted a nested case control study to investigate the incidence and risk factors for TB after allo-HSCT. Between 2012 and 2017, 730 consecutive allo-HSCT recipients were enrolled, and 14 patients (1.92%) were diagnosed with TB. Relatively, 54 allo-HSCT recipients were selected as control. Patients who suffered TB had a significantly higher 3-year non-relapse mortality rate than the control group (30.36% vs 5.39%, P < 0.01). In multivariate analysis, invasive fungal disease (HR 4.87, 95% CI 1.39–17.09), treatment with a relatively high dose of prednisone (HR 10.34, 95% CI 1.12–95.47) and treatment with tacrolimus (HR 4.79, 95% CI 1.18–19.44) were identified independent risk factors for TB occurrence post allo-HSCT (P < 0.05). Meanwhile, donor type, dose and type of anti-thymocyte globulin (ATG) administrated, as well as treatment intensity, did not alter the incidence of TB. Therefore, allo-HSCT recipients with unexplained fever, especially those who suffer from invasive fungal disease and ongoing immunosuppression with a relatively high dose of prednisone or tacrolimus, are at a high-risk of developing active TB. Closely Monitoring TB occurrence, making a timely diagnosis and administering the proper treatment may be beneficial to those high-risk patients.
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Affiliation(s)
- Apeng Yang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China.,Institute of Hematology, Zhejiang University, Hangzhou, 310003, China.,Department of Hematology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Jimin Shi
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China.,Institute of Hematology, Zhejiang University, Hangzhou, 310003, China
| | - Yi Luo
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China.,Institute of Hematology, Zhejiang University, Hangzhou, 310003, China
| | - Yishan Ye
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China.,Institute of Hematology, Zhejiang University, Hangzhou, 310003, China
| | - Yamin Tan
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China.,Institute of Hematology, Zhejiang University, Hangzhou, 310003, China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China. .,Institute of Hematology, Zhejiang University, Hangzhou, 310003, China.
| | - Yanmin Zhao
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China. .,Institute of Hematology, Zhejiang University, Hangzhou, 310003, China.
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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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Lui SL, Yap D, Cheng V, Chan TM, Yuen KY. Clinical practice guidelines for the provision of renal service in Hong Kong: Infection Control in Renal Service. Nephrology (Carlton) 2019; 24 Suppl 1:98-129. [PMID: 30900339 PMCID: PMC7167703 DOI: 10.1111/nep.13497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
| | - Desmond Yap
- Department of MedicineThe University of Hong KongHong Kong
| | - Vincent Cheng
- Department of MicrobiologyQueen Mary HospitalHong Kong
| | - Tak Mao Chan
- Department of MedicineThe University of Hong KongHong Kong
| | - Kwok Yung Yuen
- Department of MicrobiologyThe University of Hong KongHong Kong
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Abstract
The good clinical result of lung transplantation is constantly undermined by the high incidence of infection, which negatively impacts on function and survival. Moreover, infections may also have immunological interactions that play a role in the acute rejection and in the development of chronic lung allograft dysfunction. There is a temporal sequence in the types of infection that affects lung allograft: in the first postoperative month bacteria are the most frequent cause of infection; following this phase, cytomegalovirus and Pneumocystis carinii are common. Fungal infections are particularly feared due to their association with bronchial complication and high mortality. Scrupulous postoperative surveillance is mandatory for the successful management of lung transplantation patients with respect to early detection and treatment of infections. This paper is aimed to address clinicians in the management of the major infectious complications that affect the lung transplant population.
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Affiliation(s)
- Mario Nosotti
- Thoracic Surgery and Lung Transplantation Unit, Milano, Italy
| | - Paolo Tarsia
- Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Centre, Ca' Granda Foundation IRCCS Ospedale Maggiore Policlinico, Milano, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Letizia Corinna Morlacchi
- Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Centre, Ca' Granda Foundation IRCCS Ospedale Maggiore Policlinico, Milano, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
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Abstract
Mycobacterial infections are uncommon in solid organ and hematopoietic stem cell transplant recipients but carry significant morbidity and mortality. Donor screening strategies for tuberculosis should be emphasized in high-risk populations. Both tuberculosis and nontuberculous mycobacterial infections can have pulmonary and extrapulmonary manifestations of infections. Recommended treatment regimens typically involve multiple drugs with significant adverse effects and drug interactions.
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Abstract
Mycobacterium tuberculosis is a major opportunistic pathogen in transplant recipients. Compared to that in the general population, the frequency of tuberculosis (TB) is 10 to 40 times higher in hematopoietic stem cell transplant (HSCT) recipients and 20 to 74 times higher in solid-organ transplant (SOT) recipients. Transplant recipients with TB are also more likely to develop disseminated disease, have longer time to definitive diagnosis, require more invasive diagnostic procedures, and experience greater anti-TB treatment-related toxicity than the general population. Specific risk factors for TB in SOT recipients include previous exposure to M. tuberculosis (positive tuberculin skin tests and/or residual TB lesions in pretransplant chest X ray) and the intensity of immunosuppression (use of antilymphocyte antibodies, type of basal immunosuppression, and intensification of immunosuppressive therapy for allograft rejection). Risk factors in HSCT recipients are allogeneic transplantation from an unrelated donor; chronic graft-versus-host disease treated with corticosteroids; unrelated or mismatched allograft; pretransplant conditioning using total body irradiation, busulfan, or cyclophosphamide; and type and stage of primary hematological disorder. Transplant recipients with evidence of prior exposure to M. tuberculosis should receive treatment appropriate for latent TB infection. Optimal management of active TB disease is particularly challenging due to significant drug interactions between the anti-TB agents and the immunosuppressive therapy. In this chapter, we address the epidemiology, clinical presentation, diagnostic considerations, and management strategies for TB in SOT and HSCT recipients.
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Huaman MA, Brawley R, Ashkin D. Multidrug-resistant tuberculosis in transplant recipients: Case report and review of the literature. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12672] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 09/27/2016] [Accepted: 10/23/2016] [Indexed: 12/17/2022]
Affiliation(s)
- Moises A. Huaman
- Division of Infectious Diseases; University of Kentucky College of Medicine; Lexington KY USA
| | | | - David Ashkin
- Southeastern National Tuberculosis Center; Gainesville FL USA
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Immune Reconstitution Inflammatory Syndrome Occurring in a Kidney Transplant Patient with Extrapulmonary Tuberculosis. Case Rep Transplant 2017; 2017:6290987. [PMID: 28367350 PMCID: PMC5359457 DOI: 10.1155/2017/6290987] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/22/2017] [Indexed: 12/20/2022] Open
Abstract
Tuberculosis (TB) occurring in solid organ transplantation (SOT) is associated with significant morbidity and mortality usually due to delays in diagnosis, drug toxicity encountered with antimycobacterial therapy, and drug-drug interactions. TB in SOT patients may mimic other infectious and noninfectious posttransplant complications such as posttransplant lymphoproliferative disorder (PTLD) and systemic cytomegalovirus infection. Immune reconstitution inflammatory syndrome (IRIS) is a host response resulting in paradoxical worsening of an infectious disease which occurs after the employment of effective therapy and reversal of an immunosuppressed state. We describe the development of immune reconstitution inflammatory syndrome (IRIS), a unique complication occurring during the treatment of extrapulmonary tuberculosis occurring after transplant which resulted from decreasing immunosuppression in a patient who received Alemtuzumab induction therapy. Although (IRIS) has been originally described in HIV/AIDS patients receiving highly active antiretroviral therapy (HAART), solid organ transplant recipients with diagnosed or occult TB whose immune system may undergo immune reconstitution during their posttransplant course represent a new high risk group.
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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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16
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Pan SC, Chen YC, Wang JY, Sheng WH, Lin HH, Fang CT, Chang SC. Tuberculosis in Healthcare Workers: A Matched Cohort Study in Taiwan. PLoS One 2015; 10:e0145047. [PMID: 26679188 PMCID: PMC4683009 DOI: 10.1371/journal.pone.0145047] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 11/29/2015] [Indexed: 11/26/2022] Open
Abstract
Background Proportional mortality ratio data indicate that healthcare workers (HCWs) have an elevated tuberculosis (TB) mortality. Whether this is caused by an increased TB incidence, a worse TB treatment outcome, or a combination of effects, remains unclear. To elucidate the hazard components of occupational TB, we assessed TB incidence and TB treatment outcome among HCWs in Taiwan. Methods We compared the incidence of active TB among HCWs at a major medical center in Taiwan with that of Taiwan general population in 2004–2012. We also compared the TB treatment outcome of HCWs with that of age/sex-matched non-HCW patients treated at the same hospital, as well as that of nationally registered TB patients. Results The standardized TB incidence ratio of the HCWs was 1.9 (95% confidence interval [CI]: 1.2–2.9), compared with the general population. HCWs with pulmonary TB (n = 30) were less likely to have underlying diseases, delay in diagnosis, delay in treatment, or side effects of treatment, compared with age/sex-matched non-HCW TB patients (n = 120) (all Ps<0.05). The TB treatment outcome of HCWs was significantly better than that of non-HCW patients (TB-related mortality: 0.0% vs. 5.8%, P = 0.008, Mantel-Haenszel test). The standardized TB-related mortality rate was 1.08% [95% CI: 0.96% - 1.20%] for all of the nationally registered TB patients in Taiwan. Conclusions HCWs are at increased risk of active TB, compared with general population. To mitigate this occupational hazard, more efforts need to be directed towards the prevention of nosocomial TB transmission. Healthy worker effect, more rapid diagnosis, and less delay in treatment contribute to a lower TB-related mortality in HCWs.
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Affiliation(s)
- Sung-Ching Pan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsien-Ho Lin
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- * E-mail: (CTF); (HHL)
| | - Chi-Tai Fang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail: (CTF); (HHL)
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- National Taiwan University College of Medicine, Taipei, Taiwan
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17
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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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18
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Jr CSK, Koval CE, Duin DV, Morais AGD, Gonzalez BE, Avery RK, Mawhorter SD, Brizendine KD, Cober ED, Miranda C, Shrestha RK, Teixeira L, Mossad SB. Selecting suitable solid organ transplant donors: Reducing the risk of donor-transmitted infections. World J Transplant 2014; 4:43-56. [PMID: 25032095 PMCID: PMC4094952 DOI: 10.5500/wjt.v4.i2.43] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/21/2014] [Accepted: 05/14/2014] [Indexed: 02/05/2023] Open
Abstract
Selection of the appropriate donor is essential to a successful allograft recipient outcome for solid organ transplantation. Multiple infectious diseases have been transmitted from the donor to the recipient via transplantation. Donor-transmitted infections cause increased morbidity and mortality to the recipient. In recent years, a series of high-profile transmissions of infections have occurred in organ recipients prompting increased attention on the process of improving the selection of an appropriate donor that balances the shortage of needed allografts with an approach that mitigates the risk of donor-transmitted infection to the recipient. Important advances focused on improving donor screening diagnostics, using previously excluded high-risk donors, and individualizing the selection of allografts to recipients based on their prior infection history are serving to increase the donor pool and improve outcomes after transplant. This article serves to review the relevant literature surrounding this topic and to provide a suggested approach to the selection of an appropriate solid organ transplant donor.
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19
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Fagiuoli S, Colli A, Bruno R, Craxì A, Gaeta GB, Grossi P, Mondelli MU, Puoti M, Sagnelli E, Stefani S, Toniutto P, Burra P. Management of infections pre- and post-liver transplantation: report of an AISF consensus conference. J Hepatol 2014; 60:1075-89. [PMID: 24384327 DOI: 10.1016/j.jhep.2013.12.021] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 12/18/2013] [Accepted: 12/19/2013] [Indexed: 02/06/2023]
Abstract
The burden of infectious diseases both before and after liver transplantation is clearly attributable to the dysfunction of defensive mechanisms of the host, both as a result of cirrhosis, as well as the use of immunosuppressive agents. The present document represents the recommendations of an expert panel commended by the Italian Association for the Study of the Liver (AISF), on the prevention and management of infectious complications excluding hepatitis B, D, C, and HIV in the setting of liver transplantation. Due to a decreased response to vaccinations in cirrhosis as well as within the first six months after transplantation, the best timing for immunization is likely before transplant and early in the course of disease. Before transplantation, a vaccination panel including inactivated as well as live attenuated vaccines is recommended, while oral polio vaccine, Calmette-Guerin's bacillus, and Smallpox are contraindicated, whereas after transplantation, live attenuated vaccines are contraindicated. Before transplant, screening protocols should be divided into different levels according to the likelihood of infection, in order to reduce costs for the National Health Service. Recommended preoperative and postoperative prophylaxis varies according to the pathologic agent to which it is directed (bacterial vs. viral vs. fungal). Timing after transplantation greatly determines the most likely agent involved in post-transplant infections, and specific high-risk categories of patients have been identified that warrant closer surveillance. Clearly, specifically targeted treatment protocols are needed upon diagnosis of infections in both the pre- as well as the post-transplant scenarios, not without considering local microbiology and resistance patterns.
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Affiliation(s)
- Stefano Fagiuoli
- Gastroenterology and Transplant Hepatology, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | | | - Raffaele Bruno
- Department of Infectious Diseases, IRCCS San Matteo, University of Pavia, Pavia, Italy
| | - Antonio Craxì
- Gastroenterology and Hepatology, Di.Bi.M.I.S., University of Palermo, Italy
| | - Giovanni Battista Gaeta
- Infectious Diseases, Department of Internal and Experimental Medicine, Second University of Naples, Italy
| | - Paolo Grossi
- Infectious & Tropical Diseases Unit, Department of Surgical & Morphological Sciences, Insubria University, Varese, Italy
| | - Mario U Mondelli
- Research Laboratories, Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo and Department of Internal Medicine, University of Pavia, Italy
| | - Massimo Puoti
- Infectious Diseases Department, Niguarda Cà Granda Hospital, Milano, Italy
| | - Evangelista Sagnelli
- Department of Mental Health and Preventive Medicine, Second University of Naples, Italy
| | - Stefania Stefani
- Department of Bio-Medical Sciences, Section of Microbiology, University of Catania, Italy
| | - Pierluigi Toniutto
- Department of Medical Sciences, Experimental and Clinical, Medical Liver Transplant Section, Internal Medicine, University of Udine, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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20
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Regmi A, Singh P, Harford A. A Case of Multidrug-Resistant Monoarticular Joint Tuberculosis in a Renal Transplant Recipient. Transplant Proc 2014; 46:274-7. [DOI: 10.1016/j.transproceed.2013.07.071] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 07/24/2013] [Indexed: 02/04/2023]
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21
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Hickey MD, Quan DJ, Chin-Hong PV, Roberts JP. Use of rifabutin for the treatment of a latent tuberculosis infection in a patient after solid organ transplantation. Liver Transpl 2013; 19:457-61. [PMID: 23526600 DOI: 10.1002/lt.23622] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 01/26/2013] [Indexed: 02/07/2023]
Abstract
Latent tuberculosis infection is an important problem for solid organ transplant recipients because of the frequency of its occurrence and its potential for reactivation. Because of the high mortality rate associated with active tuberculosis infections in transplant recipients, guidelines from the American Thoracic Society recommend treatment for latent tuberculosis in this population. However, the choice of treatments is often difficult because liver transplant recipients may be more sensitive to isoniazid hepatotoxicity, and rifampin has significant drug interactions with the calcineurin inhibitors used for immunosuppression. Two prior case reports described success with the use of rifabutin, a rifampin alternative, as part of a multidrug treatment regimen for active tuberculosis in posttransplant patients; however, there is no prior literature describing any experience with rifabutin for the treatment of latent tuberculosis in the posttransplant setting. We present a summary of tacrolimus drug levels and corresponding dose requirements for a single posttransplant patient during the administration of 3 different latent tuberculosis drug regimens: rifampin alone, rifampin plus ketoconazole, and rifabutin. In this patient's case, rifabutin allowed the maintenance of adequate tacrolimus levels, although an approximate 2.5-fold increase in the dose was required. Rifampin alone was associated with inadequate immunosuppressant levels, and rifampin plus ketoconazole was associated with a problematically prolonged QT interval and concerns about inadequate tuberculosis treatment.
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Affiliation(s)
- Matthew D Hickey
- School of Medicine, University of California San Francisco, San Francisco, CA 94143-0454, USA.
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22
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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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23
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Muñoz P, Fernández NS, Fariñas MC. Epidemiology and risk factors of infections after solid organ transplantation. Enferm Infecc Microbiol Clin 2012; 30 Suppl 2:10-8. [DOI: 10.1016/s0213-005x(12)70077-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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