LETTER TO THE EDITOR
Year : 2011 | Volume
: 22 | Issue : 6 | Page : 1266--1268
The prevalence of tuberculosis in recipients of renal transplantation
MJ Mojahedi1, Behzad Feizzadeh2, B Aghdam1, R Hekmat1,
1 Department of Kidney Transplantation, Endoscopic and Minimally Invasive Surgery Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
2 Department of Urology, Endoscopic and Minimally Invasive Surgery Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
Department of Urology, Endoscopic and Minimally Invasive Surgery Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad
|How to cite this article:|
Mojahedi M J, Feizzadeh B, Aghdam B, Hekmat R. The prevalence of tuberculosis in recipients of renal transplantation.Saudi J Kidney Dis Transpl 2011;22:1266-1268
|How to cite this URL:|
Mojahedi M J, Feizzadeh B, Aghdam B, Hekmat R. The prevalence of tuberculosis in recipients of renal transplantation. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2020 Feb 26 ];22:1266-1268
Available from: http://www.sjkdt.org/text.asp?2011/22/6/1266/87253
To the Editor,
The prevalence of tuberculosis (TB) one of the ancient diseases in the world, has increased in the recent years because of the use of immunosuppression for organ transplantation, HIV infection, and increasing incidence or recognition of other immunologic disorders. TB after transplantation is more common in developing and under-developed countries, probably due to higher rates of malnutrition, poverty and illiteracy. ,, The incidence of TB in these cases is reported 36-74 times more than general population both because of the use of immunosuppressive agents and reactivation of latent infections.  Post trans-plantation TB causes cosiderable morbidity and mortality ,. TB in patients undergoing dialysis is reported to be ten times more common but there are no accurate estimation of TB prevalence in renal transplant recipients. Available reports varies and is different from each other. ,,
The aim of this study is to evaluate the prevalence of tuberculosis in recipients of renal transplantation in our hospital. A total of 508 renal transplantation cases, who underwent renal transplantation surgery from 1989 to 2006 in our hospital and were on follow up with us, were included into the study. All patients were on immunosupression with triple drug regime with cyclosporine, azathioprine, or mycophenolate mofetil and prednisolone. All patients were under co-trimoxazole prophylaxis for the first six months. Follow up period ranged from one to 14 years (mean 4.5 yrs).
Age of patients ranged from 20 to 36 years (mean age 35.5 years) and male to female ratio was 350/158 (M/F=2.2/1). 432 patients (85%) were on hemodialysis and 76 patients (15%) were on peritoneal dialysis before transplantation.
Purified protein derivative (PPD) test was performed before transplantation in all patients and if it was positive (PPD >10 mm) isoniazid (INH) prophylaxis was given from the first day after transplantation up to six months (300 mg/d). If fever, pulmonary symptoms, weight loss, fatigue, malaise and/or lymphadenopathy were detected, then supplementary evaluations such as sputum smear, chest X-Ray (CXR), broncoscopy, bronchoalveolar lavage (BAL) and trans-bronchial lung biopsy or pleural or lymph node biopsy were performed as indicated. Data was analyzed by Statistical Package for the Social Sciences (SPSS) and P < 0.05 was considered statistically significant.
Pre-transplant CXR did not show any signs of TB in both donors and recipients. PPD >10 mm was not seen in any of the donors. Among 508 recipients, 64 cases (12.59%) had PPD >10 mm but among them only one patient developed active TB, whereas among 444 cases with negative PPD, TB was seen in eight cases (P > 0.05).
None of the patients gave history of taking treatment for TB infection before undergoing transplantation. Among 508 patients, nine cases (1.77%) in the age range from 18 to 52 years (mean 35 years) were infected by M. tuberculosis. Six patients were females (66.6%) and three were males (33.4%) (M/F=1:2). In five patients (55.5%), TB was diagnosed during the first year after transplantation and in three cases (33.3%) during the second year and in one case (11.1%) the third year after kidney transplantation. The most common signs and symptoms that led to TB diagnosis were fever (resistant to common antibiotics) in eight cases (88.8%), cough in eight patients (88.8%), productive cough in seven cases (77.7%), dyspnea in six cases (66.6%), pleuritic pain in two (22.2%) and lymphadenophathy in one patient (11.1%).
Radiologic findings in documented tuberculosis cases showed unilateral or bilateral pulmonary infiltration in six cases (66.6%) and pleural effusion in two cases (22.2%). Among nine TB cases, five cases had pulmonary TB (55.5%), pleural TB was diagnosed in two patients (22.2%) and cervical TB lymphadenopathy and TB in the native kidney were observed in one patient (11.1% ) each.
Episodes of acute rejection needing treatment had occurred in four patients (44.5%), one to six months before the diagnosis TB and in two cases, acute rejection developed after initiating anti-TB treatment.
Among nine cases, three recipients (33.3%) were sputum smear positive for acid fast bacilli, two (22.2%) cases were diagnosed by trans-bronchial biopsy and two cases by pleural biopsy. Diagnosis was obtained by lymph node biopsy in one patient (11.1%) and by native kidney nephrectomy in the other case (11.1%). One patient died because of severe pulmonary symptoms and resistance to anti-Tb drugs. Two cases needed hemodialysis again in the second year, because of chronic rejection.
There are several reasons for the inceased susceptibility of post transplant patients to TB. Immunosuppressive agents such as cyclosporine may reactivate Mycobacterium Tuberculosis (MTB) because cyclosporine have interaction with Interleukin 2(IL2) and tumor necrosis factor 8 (TNF8) release which are needed for lymphocyte clonal expansion and also migration and activation of macro-phages. Lymphokines blockage cause reactivation, reproduction and spreading of latent MTB bacilius. Similar mechanism in chronic kidney disease lead to skin anergy and diminishes the role of PPD test for diagnosis of TB in such cases. ,,
In developing countries, pulmonary infections after renal transplantation are more prevalent because of TB or fungal infection. ,,, Prevalence of pulmonary infections are 0.5-1% in US, 1- 4% in Europe and up to 11% in the underdeveloped countries. ,,
In a study from India on 1414 renal transplantation cases with 3.1 years of follow up showed that 11.7% had TB. , The rate of TB in the other studies was 15.6% in India, 3.5% in middle east, 4% in Turkey and 7% in South Africa. ,,, Prevalence of tuberculosis in our study was only 1.77% which is less than other reports from most centers in this region. This may be due to INH prophylaxis we used in PPD positive recipients.
Various reports show that the time of onset of TB infection is variable in these patients. In most cases, it occurs in the first year after kidney transplantation ,,, . In our study, TB was diagnosed during the first year after transplantation in five patients (55.5%), in three cases (33.3%) the second year and in one patient (11.1%) the third year. Pulmonary TB (55.5%) was the most common type of M. TB infection.
Several risk factors contribute to higher rate of TB infection in post transplant cases, such as use of cyclosporine, hepatitis C infection, diabetes mellitus, chronic hepatic failure, fungal infection, cytomegalovirus, pneumocystis carini, nocardia infections and SLE. , These risk factors except cyclosporine use were not a factor in our patients.
Role of TB in graft rejection is controversial in different studies. In one trial, TB prevalence was 58.6% in chronic rejection of renal transplants, but other researches did not confirm this finding.  Among our cases, two patients (22.2%) had chronic rejection and were put back on regular hemodialysis. A study reported that mortality rate in the patients with tuberculosis was 30%,  but mortality rate among our patients was only 11.1%.
Thus in this study, prevalence of TB was less than many other centers which may be attributed to the prophylactic use of INH in PPD positive cases. Incidence of TB was more common in the first year after transplantation and pulmonary TB was the most prevalent. Further studies with larger samples is required to have more conclusive results.
The authors would like to thank Mrs. Tooran Makhdoomi who helped us in preparation of this manuscript.
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