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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 5  |  Page : 790-792
Tuberculosis in a Renal Allograft: A Successful Outcome


1 Department of Internal Medicine, Christian Medical College and Hospital, Ludhiana, India
2 Department of Nephrology, Christian Medical College and Hospital, Ludhiana, India
3 Department of Pathology, Christian Medical College and Hospital, Ludhiana, India

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   Abstract 

Tuberculosis is endemic in most South-East Asian countries including India. It causes significant morbidity and mortality in renal transplant recipients and often, it is not diagnosed early, due to its innocuous clinical presentations. A high index of suspicion and proactive management in the early phase of presentation can reduce allograft nephropathy, graft nephrectomy and mortality. A patient with an unusual presentation of tuberculosis localized to the allograft and successful management with anti-tuberculosis medications is described.

Keywords: Anti tuberculosis therapy, Granuloma, Renal allograft tuberculosis

How to cite this article:
George P, Pawar B, Calton N. Tuberculosis in a Renal Allograft: A Successful Outcome. Saudi J Kidney Dis Transpl 2008;19:790-2

How to cite this URL:
George P, Pawar B, Calton N. Tuberculosis in a Renal Allograft: A Successful Outcome. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Oct 17];19:790-2. Available from: http://www.sjkdt.org/text.asp?2008/19/5/790/42461

   Introduction Top


Tuberculosis is endemic in most South-East Asian countries including India. The preva­lence of post-transplant tuberculosis in India was 11.8% [1] and 13.3% [2] in studies performed in tertiary care centers in North and South India, respectively. It is a risk factor for mortality with one third of these patients dying of the disease. [2] Genitourinary tuberculosis is associated with graft rejection and should be considered in renal transplant recipients with unexplained fever and constitutional symptoms. In renal transplant patients, tuberculosis is likely to take the form of pulmonary or disse­minated disease. [3] Tuberculosis isolated to the renal allograft and causing allograft dysfunc­tion, diagnosed by percutaneous allograft biop­sy, and successful management with anti­tuberculosis therapy (ATT) is a rare success story.


   Case Report Top


A 27–year-old lady, who underwent live unrelated donor renal transplantation 15–months earlier, was admitted with fever and vomiting of one days duration. She had undergone her first renal transplantation (related donor) 14­years earlier. This graft was lost due to chronic allograft nephropathy and the second trans­plant was performed in Pakistan. No details of the transplantation or kidney donor were avai­lable. The graft function post-transplantation was normal.

Two weeks prior to the present hospita­lization, she had undergone total hip replace­ment (THR) for avascular necrosis of the femur on the left side. Her initial presentation with difficulty to move the hip three months earlier had shown a comminuted fracture of the femur and intra-operative findings revealed an erythematous and hypertrophied synovium with about 20 ml of pus. Pus culture for pyo­genic, tuberculous and fungal elements was sterile. Biopsy of the bone and synovium showed signs of chronic inflammation but no granuloma. The PCR analysis of the pus tested positive for mycobacterium genus but was negative for tuberculosis. As the patient had no constitutional symptoms or evidence to sug­gest infection other than the mycobacterium genus detected in the pus, a decision not to treat with anti-tuberculous (ATT) medication was taken. The patient improved with Buck's traction. Once the tissue swelling subsided, the THR was performed. The patient had an uneventful recovery and was ambulant at discharge with normal urine output and renal function. Her medications at discharge inclu­ded cyclosporine, mycophenolate mofetil and prednisolone with calcium and vitamin supple­mentation.

When seen at present hospitalization, the fever was of moderate grade and continuous, with no chills or rigors, and was relieved with paracetamol. She had recurrent, non-bilious, non-projectile vomiting but no abdominal pain or obstipation. Clinical examination was normal. However, investigations revealed blood urea of 64 mg/dl, serum creatinine 2.5 mg/dL, serum potassium 5 meq/L, serum uric acid 11.8 mg/ dL, serum calcium 9.7 mg/dL, serum phos­phorus 5.8 mg/dL and hemoglobin of 8.5 gm/ dL. The patient had, in addition, leukocytosis with neutrophilia. Pyuria was seen on urina­lysis and the urine culture grew E. coli which was treated with gatifloxacin. No eosinophi­luria was seen. Liver function tests were normal, as was the allograft and its vascular perfusion on ultrasonography. Repeated uri­nalysis for acid fast bacilli and culture was negative as was the urine PCR for tuber­culosis. Dialysis was initiated in view of worsening renal failure and an allograft biopsy was done thereafter. The biopsy showed gra­nulomas with necrosis [Figure 1]. Immuno­fluorescence was negative. Renal allograft tuberculosis was diagnosed and she was put on ATT with rifampicin, isoniazid, ethambutol and pyrazinamide. Cyclosporine was replaced by sirolimus and mycophenolate mofetil and pred­nisolone were continued. Bi-weekly hemo­dialysis was planned and within a week of starting ATT the fever subsided and renal function tests showed a steady improvement to normal within three weeks. On out patient follow up, she has been afebrile with normal renal function after completion of the four months of ATT.


   Discussion Top


Infection with Mycobacterium tuberculosis after transplantation usually occurs due to re­activation of an earlier quiescent focus, or rarely by infection transmitted through the donor kidney; the latter is rare accounting for less than five percent of patients with post­transplant tuberculosis. [4] The organism has stringent growth requirements and the kidney is one of the few extra-pulmonary sites for proliferation, especially in the renal medulla, where confluent epithelioid granuloma with caseous necrosis are seen leading to local tissue destruction. [5] Fever, without genitourinary symptoms is a common presentation of post­transplant tuberculosis and the diagnosis may be made by the detection of mycobacteria or PCR analysis of the urine. [3] This patient pre­sented an unique problem as the urine tests were normal and no other source of tuber­culosis could be isolated; however, the allo­graft biopsy showed granuloma suggestive of tuberculosis. A possible reason for not seeing acid fast bacilli (AFB) on Zieil Nielsen stai­ning may be that the patient had received quinolones for two weeks for treatment of urinary tract infection; these drugs are used as second line anti-tuberculous drugs. Additionally, in our patient, the presence of granulomas on biopsy points to the possibility of an insidious underlying disease process because tubercu­lous granulomas are usually seen after about a year after transplantation. [6] An infected donor kidney, as the source, would have resulted in an exudative form in the immediate post-trans­plant period. Whether the change of medica­tion from azathioprine to mycophenolate mo­fetil about a year earlier influenced the reacti­vation is open to speculation. Reactivation of tuberculosis with mycophenolate mofetil has been reported even late post-transplantation. [7]

An earlier case report has described a patient with renal allograft dysfunction in whom percutaneous biopsy showed tuberculosis. The patient recovered renal function after anti­tuberculous therapy. Tuberculosis isolated to the renal allograft, especially in an endemic area, may be the cause of renal dysfunction, and appropriate therapy could lead to salvage of the graft. [8] Immunosuppressive regimens that comprise of tacrolimus (TAC), mycophe­nolate mofetil (MMF) and prednisolone are reported to be associated with fewer episodes of rejection, a lower need for steroids and better peri-operative graft function. [9] However, immunosuppression with TAC or MMF is associated with the development of tuber­culosis earlier in the post-transplant period and in younger patients. [10]

Tuberculosis is a serious complication after renal transplantation, particularly in develo­ping countries, often resulting in graft nephrec­tomy. In view of its atypical clinical manifes­tation, all renal allograft recipients should be carefully evaluated for the development of tuberculosis. Renal biopsy is helpful when other investigations are inconclusive with a backdrop of allograft dysfunction.

 
   References Top

1.Sakhuja V, Jha V, Varma PP, Joshi K, Chugh KS. The high incidence of tuberculosis among renal transplant recipients in India. Transplan­tation 1996;61(2):211-5.  Back to cited text no. 1    
2.John GT, Shankar V, Abraham AM, Mukundan U, Thomas PP, Jacob CK. Risk factors for post­transplant tuberculosis. Kidney Int 2001; 60(3):1148-53.  Back to cited text no. 2    
3.Dowdy L, Ramgopal M, Hoffman T, et al. Genitourinary tuberculosis after renal trans­plantation: report of 3 cases and review. Clin Infect Dis 2001;32(4):662-6.  Back to cited text no. 3    
4.Siu YP, Tong MK, Leung KT, Yung CY. Successful kidney re-transplantation in a patient with previous allograft kidney tuber-culosis. Transpl Infect Dis 2004:6(3):132-5.  Back to cited text no. 4    
5.Eastwood JB, Corbishley CM, Grange JM. Tuberculosis and the kidney. J Am Soc Nephrol 2001:12(6):1307-14.  Back to cited text no. 5    
6.Biz E, Pereira CA, Moura LA, et al. The use of cyclosporine modifies the clinical and histo­pathological presentation of tuberculosis after renal transplantation. Rev Inst Med Trop Sao Paulo 2000;42(4):225-30.  Back to cited text no. 6    
7.Waiser J, Schotschel R, Budde K, Neumayer HH. Reactivation of tuberculosis after conver-sion from azathioprine to mycophenolate mofetil 16 years after renal transplantatioin. Am J Kidney Dis 2000;35(3):E12.  Back to cited text no. 7    
8.Lorimer I, Botha J, Pontin AR, Pascoe MD, Kahn D. Tuberculosis isolated to the renal allograft. Transpl Infect Dis 1999;1(1):83-6.  Back to cited text no. 8    
9.Jain A, Kashyap R, Dodson F, et al. A pros­pective trial of tacrolimus and prednisone versus tacrolimus, prednisone and mycopheno-late mofetil in primary adult liver transplant-tation: a single center report. Transplantation 2001;72 (6):1091-7.  Back to cited text no. 9    
10.Atasever A, Bacakoglu F, Toz H, et al. Tuber­culosis in renal transplant recipients on various immunosuppressive regimens. Nephrol Dial Transplant 2005;20(4):797-802  Back to cited text no. 10    

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Correspondence Address:
Pratish George
Department of Internal Medicine, Christian Medical College and Hospital, Brown Road, Ludhiana- 141 008, Punjab
India
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PMID: 18711297

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    Abstract
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