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Saudi Journal of Kidney Diseases and Transplantation
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REVIEW ARTICLE Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 2  |  Page : 189-199
Infection and Cancer Following Renal Transplantation


Consultant Nephrologist, Royal Free Hospital, London, United Kingdom

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   Abstract 

Ever increasingly potent but non-specific immunosuppression has necessarily brought with it the continuing risk of opportunistic infections and virus-induced malignancies. The improvement in graft and patient survival rates from transplantation has depended to a certain extent on parallel improvements in the diagnosis and treatment of infectious complications. This review will highlight some of the current problems and progress. The risks of infection are largely related to the total burden of immunosuppression rather than any particular drug, although sirolimus and the anti CD25 antibodies may be an exception. Almost all the post-transplant infections are treatable; a precise microbiological diagnosis is essential so that specific therapy can be used. Newer molecular diagnostic techniques are increasingly widely available, e.g.quantitative polymerase chain reaction. The transplant community will inevitably be faced with highly resistant bacteria such as. Methicillin resistant Staphylococcus Aureus (MRSA) and will have to develop appropriate strategies. New infectious organisms continue to be identified [e.g. Burkitt's Virus (BKV), West Nile virus and Avian influenza) and will continue to tax the ingenuity of transplant physicians and microbiologists.

How to cite this article:
Sweny P. Infection and Cancer Following Renal Transplantation. Saudi J Kidney Dis Transpl 2006;17:189-99

How to cite this URL:
Sweny P. Infection and Cancer Following Renal Transplantation. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2020 Jun 5];17:189-99. Available from: http://www.sjkdt.org/text.asp?2006/17/2/189/35789

   Introduction Top


The range of microorganisms encountered post-transplantation [1] is very similar to that seen in a patient with the acquired immuno­deficiency syndrome (AIDS) [Table - 1] and is clearly a direct consequence of potent immuno­-suppression (IS). The timetable for infection [2] is a helpful concept. In the first month, micro­organisms encountered are usually those seen after any invasive operation undertaken in a hospital, e.g. wound, chest and catheter related infections. Wound infections can be serious as they may reach to the anastamotic site and be followed by the development of a mycotic aneurysm with a subsequent catastrophic fatal rupture. Between month one and month six, when IS is at its height, opportunistic infections occur [Table - 1]. After six months, provided graft function is good, (and IS is reduced to a lower maintenance dose) the risk of infection reduces towards normal but remains increased with patients at risk for the rest of the life of the transplant.

Cytomegalovirus (CMV)

CMV remains an important post-transplant pathogen. [3],[4],[5] Diagnosis is available in real time [PP65 antigen testing or polymerase chain reaction, (PCR)] and quantitative viral loads help in guiding management. The rate of increase provides an indication of the risk of disease. [6] Opinion is more or less equally divided between employing universal prophylaxis or pre-emptive therapy [Table - 2]. [7] The threat of CMV has largely been contained but increasing knowledge about the indirect effects of CMV continues to interest the transplant community [Table - 3].[8] A vaccine is in development.

The Viral-Induced Cancers

The risk of developing malignancy is about 2-3 fold increased following renal transplant­ation if all tumors are taken into account. Certain viral-induced tumors are increased many hundred fold. [9],[10] Mechanisms include loss of immune surveillance because of immunosupression, increased TGFβ particularly with cyclosporin A, and both direct and indirect effects of certain viruses [11],[12] which produce various virokines and anti-apoptotic proteins [Table - 4]. The human herpes virus HHV 4 (or the Epstein-Barr virus) and HHV8 (or the Kaposi sarcoma virus) can induce malignancy. Both hepatitis B and C viruses (HBV and HCV) are associated with hepato­cellular cancer (HCC). [13],[14] The human papilloma virus (HPV) is responsible for squamous cell carcinoma (SSC) of the skin and anogenital areas.

Other malignancies associated with trans­plantation are listed in [Table - 5].

Post-Transplant Lymphoproliferative Disorder (PTLD)

PTLD arises in 1-2% of the renal transplant population. The incidence is higher when EBV antibody positive donors donate to EBV antibody negative recipients (e.g. children receiving a live donor transplant from their parent) and is increased if the patient receives augmented immunosuppression or develops CMV. PTLD is a complex group of conditions in which B cells (or less frequently T cells) proliferate and can spread widely to produce a range of conditions ranging from a glandular fever-like syndrome to an obvious lymphoma [Table - 6]. [15],[16] In most cases, PTLD is a B­cell proliferative state induced by the EBV virus (85%). [14] The diagnosis is based on immunohistology that relies on the demon­stration of EBV coded proteins expressed in B-cells (eg. Epstein-Barr nuclear antigen - EBNA).

Accurate classification is important and has implications for prognosis and management. Early lesions in which there is no evidence of monoclonality and no oncogene expression behave more like an infection than a cancer and may regress completely with immuno­suppression dose reduction (ISDR). If diagnosis is delayed and frank malignant transformation has occurred, then additional strategies are required [Table - 6]. Recently, two new forms of effective treatment have been employed. The anti CD20 humanized monoclonal anti­body, rituximab [17] and cytotoxic T lymphocytes (CTL) have been very effective. [18] Despite these forms of therapy, some patients do require conventional cytotoxic therapy when the tumor is life threatening. There is an increased risk of overwhelming infection when cytotoxic therapy follows on from post-transplant immunosuppression. Some case reports indicate that changing immunosuppression to sirolimus may be beneficial [19] Anti IL-6 antibody may also be of benefit.[20],[21]

Kapost's Sarcoma

The incidence of Kaposi's sarcoma (KS) parallels the prevalence of HHV8 antibody in the general population. It occurs in <0.5% of transplant patients in Northern Europe and the US but is seen in nearly 5% of transplant patients from endemic areas, e.g. Saudi Arabia and the Mediterranean population. KS is induced by the HHV8 virus [19] and usually presents at 18-24 months post-transplant. [22],[23] In some cases, the disease is limited to the skin but visceral spread may occur (40%). The con­dition can be fatal when widespread. As with PTLD, the diagnosis is made by immuno­histology.

Again, as with PTLD, ISDR may be associated with tumor regression in many but not all cases. Recently, there have been several publi­cations suggesting that changing immuno­suppression from a calcineurin inhibitor (CNI) and mycophenolate mofetil (MMF) to sirolimus is associated with tumor regression without the attendant risk of rejection that occurs with immediate or rapid ISDR. [24],[25] This is the first time that a potent immuno­suppressive agent in its own right has been shown to have anti-tumor properties. [23] As with PTLD, lesions which do not regress with these measures may respond to conventional cytotoxic therapy.

Squamous Cell Cancer (SCC)

The relationship between HPV and skin SCC is less clear than that between EBV and PTLD and HHV8 and KS.[26],[27],[28] However, the relationship between the HPV and anogenital cancer [29] is much more secure [Table - 7]. Nevertheless, HPV does express genes that clearly could have an important role in promoting SCC and some particular types of the virus are closely related to anogenital cancers [Table - 7]. ISDR is also indicated in the presence of SCC but of itself is less effective than in PTLD or KS. In patients of skin type I and II, SCCs of the skin are extremely common and after 20 years of immuno­suppression nearly 80% of patients may be affected [Table - 8]. Sun exposure is clearly very important. It is important to note that there is a field change in the skin induced by the HPV. Various immunomodulating forms of therapy [30],[31],[32] can be used to reduce the risk of actinic keratosis changing into overt SSCs (imiquimod, retinoids and topical diclofenac) [Table - 9].

The Role of Antivirals in Post­ Transplant Tumors

The EBV virus responds to acyclovir but only as far as proliferative/lytic cycles are concerned. In PTLD, EBV is present in a non-proliferating form as episomal DNA, which is not susceptible to antiviral therapy. Nevertheless, some studies have shown that the incidence of PTLD is reduced in patients receiving prophylactic acyclovir. [33] It is possible that viral dissemi­nation from some lytic cycles present in the tumor are responsible for further spread.

A similar argument applies to KS as ganci­clovir is effective in vitro against the HHV8 virus. When retransplantation is considered in patients who have had PTLD or KS, prophylactic antivirals and immunosuppression using sirolimus should be considered.

HPV is susceptible to cidofovir and topical therapy may have a role to play in anogenital cancer in addition to local excision and ISDR. [34],[35] Again, attempts to preserve the graft without provoking rejection by the use of sirolimus are being attempted. Sirolimus therapy is not the only answer to post-transplant cancers as tumors have arisen in patients immunosuppressed with sirolimus although there is data to suggest that the risk of cancer in sirolimus patients is reduced.[35],[36]

Hepatocellular Cancer (HCC)

Both HBV and HCV infection are associated with an increased incidence of HCC, parti­cularly in the presence of cirrhosis and probably in the transplant carrier in general. [37],[38],[39] It is likely that the incidence and rate of progression will be increased in the transplant recipient. It is not known whether prolonged treatment with lamivudine post-renal transplant will reduce the risks of HCC. Viral resistance is likely to be a problem with prolonged therapy. Treatment of HCV post-transplantation is unsatisfactory as IFNα may provoke acute rejection.

BK Virus and BK Nephropathy

The BK virus has a predilection for the distal tubular cells of the kidney. Reactivation after transplant is common (60%) and can cause a specific interstitial nephritis (1-8%) which if it develops can result in a 50% rate of graft loss. [40] Most cases develop within the first year but continued monitoring is recom­mended for several years. [41] Monitoring can be by urine cytology (decoy cells) or urine E/M. Positive results require confirmation by PCR. Renal biopsy is diagnostic as sections can be stained for BKV antigens.

Although controlled trials are not available, cidofovir may be of value in low doses as the drug is concentrated in the kidney.[42] ISDR may be sufficient without antiviral agents.


   Bacterial Infections Post-Renal Transplantation Top


Although diagnosis and treatment are rela­tively straightforward, some infections remain a problem for the transplant patient.[43],[44] Listeria can cause a septicemic illness and meningitis. Nocardia is somewhat similar in its clinical presentation to Staphylococcus aureus Scientific Name Search  causing cavitating pneumonia, skin and muscle abscesses and occasionally a space-occupying lesion (SOL) in the brain. The main concern with bacterial infections post-transplant is with mycobacteria both tubercular and atypical infections. Reactivation of  Mycobacterium tuberculosis Scientific Name Search  common and may present with any of many different symptoms, eg, pneumonia, skin, joint and a CNS SOL. [45] In at risk patients, isoniazid prophylaxis is usually effective but care should be taken in patients with pre-existing liver disease. The drug interactions between anti­tuberculous drugs (particularly rifampicin) and immusuppressants (particularly the CNI and sirolimus) are important. It may be necessary to administer two or three times the usual dose to get effective blood levels, and the CNI may need to be administered three times daily. Accurate diagnosis is crucial and resistance testing (now available by molecular biological techniques) is important as resistance is an increasing problem. If atypical mycobacterial infection is found, then resistance testing is essential as treat­ment regimens may be complex and need to be prolonged.

Urinary Tract Infections

Urosepsis is the commonest cause of septi­cemia post-transplant. Infection within the first few months is potentially the most damaging and can cause an acute graft pyelonephritis. [46] After six months, most infections are of the lower tract and will respond to short courses of appropriate antibiotics. Some patients have recurrent frequent infections and may develop progressive scarring in the graft. Such patients require full investigation and may benefit from long-term rotating or suppressive antibiotics. Infection may occur with urea splitting organisms (eg. corynebacterium urealyticum) which leads to calcium deposition in the calyces, collecting system, ureter and bladder, viz. encrusted pyelitis.[47]

Fungal Infections

Deep fungal infections remain a serious and potentially fatal complication of organ trans­plantation. 48 The risk factors are summarized in [Table - 10]. Diagnosis often requires biopsy as well as culture. Some molecular diagnostic tests are available [Table - 11]. Over the last few years newer antifungal drugs have been introduced which are less toxic than ampho­tericin (eg. Voriconazole, posiconazole and caspofungin, mycofungin).[49],[50]

Pneumocystis pneumonia (PCP) (caused by pneumcystis jirovecii) is a serious complication of renal transplantation,[51] which is rarely seen these days as almost all patients, are routinely prophylaxed with co-trimoxazole. The clinical presentation of a patient with cough, fever and breathlessness raises a long list of diagnostic possibilities. Most cases will turn out to be community acquired viral infections, which are likely to be self-limiting. In order to identify patients at risk of a much more serious infection, oxygen saturations before and after exercise should be done and can identify patients who need admission and probable bronchoalveolar lavage.

Parasitic Infections

In certain geographical areas, strongyloides stercoralis is a serious and potentially fatal post-transplant infection. A pre-transplant eosinophilia may be present but is lost in the presence of steroid therapy. Serological testing is available. This parasite can complete its life cycle in the immunosuppressed host. Penetration of larval forms through the gut wall can result in recurrent episodes of gram negative sepsis. More than one course of thia­bendazole may be required for eradication.

Diagnostic Techniques

The molecular biological revolution is having a great impact on the diagnostic tools available to the clinicians [Table - 11]. Viral infection, particularly CMV, can be diagnosed in a matter of few hours and treatment started before patients became sick. Response to treatment can be followed and duration of therapy appro­priately adjusted in the light of quantitative PCRs.

Patients at risk of PTLD and KS may be identified by rising titers of viral DNA in the blood. The decision for a renal biopsy to diagnose BKV nephropathy can be made from a high viral load in the blood. Some resistance testing for MTB can be obtained without the need for prolonged culture. The range of diagnostic tests available and the need to apply them appropriately means that the transplant team must develop a close working relationship with the microbiologist.


   Conclusions Top


The most important post-transplant infection is CMV but effective prophylactic or pre­emptive strategies have gone a long way to minimizing its deleterious effects. In fair skinned races, HPV related skin lesions have become increasingly common post-transplant. Diagnosis at the pre-malignant stage allows for early ISDR and the use of immune modifying topical therapies to reduce the risk of overt cancer.

Perhaps the most feared complication is EBV­induced PTLD but the advent of rituximab and CTL therapy means that not only can the disease be controlled but also the graft is preserved. In certain parts of the world, a very different spectrum of infection and cancer is seen (e.g. in Saudi Arabia). The hepatitis viruses, KSV and mycobacterial infection pose a significant threat to these immuno­suppressed organ recipients. Prophylaxis by pre-transplant vaccination (eg. HBV and soon EBV, CMV and HPV) will dramatically reduce the burden of post-transplant infection and hopefully also of malignancy. Better monitoring allows for timely ISDR and there is now the possibility of switch regimens away from the CNI drugs.[52] Recently published guide­lines for the prevention and management of infectious complications of solid organ transplantation are required reading for all who care for solid organ transplant recipients. [52]

 
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Correspondence Address:
Paul Sweny
Consultant Nephrologist, Royal Free Hospital, London
United Kingdom
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    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8], [Table - 9], [Table - 10], [Table - 11]

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