Year : 2019 | Volume
: 30 | Issue : 3 | Page : 560--563
Rabies, rabies vaccine, and renal failure: Clinical issues
Won Sriwijitalai1, Viroj Wiwanitkit2,
1 RVT Medical Center, Bangkok, Thailand
2 Department of Community Medicine, Dr. D. Y. Patil University, Pune, Maharashtra, India; Department of Biological Science, Joseph Ayobabalola University, Ilara-Mokin, Nigeria; Department of Medical Science, Faculty of Medicine, University of Nis, Nis, Serbia
RVT Medical Center, Bangkok
Rabies is an important neurological infection that is prevalent in tropical countries. The rabid animals can bring rabies to humans by biting. The disease can result in serious neurological problem and death is the end result. The best way is prevention of disease by postexposure prophylaxis against rabies. The effect of rabies on the renal system is little mentioned in the literature. In the previous literature, acute kidney injury was observable in half of the rabies patients. Rabies is also transmittable by organ transplantation. Although it is rare and <10 cases had ever been reported in literature, it is proven that kidney transplant patients are at risk of getting rabies if the donor come from endemic country or with a history of travel to endemic country and has unclear cause of death. Regarding rabies immunization, the use of vaccination for patients with the underlying renal failure is interesting. In this short article, the authors summarize on those important clinical issues of rabies and renal failure.
|How to cite this article:|
Sriwijitalai W, Wiwanitkit V. Rabies, rabies vaccine, and renal failure: Clinical issues.Saudi J Kidney Dis Transpl 2019;30:560-563
|How to cite this URL:|
Sriwijitalai W, Wiwanitkit V. Rabies, rabies vaccine, and renal failure: Clinical issues. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2020 Jun 2 ];30:560-563
Available from: http://www.sjkdt.org/text.asp?2019/30/3/560/261327
Rabies is an important neurological infection that is prevalent in tropical countries. The rabid animals can bring rabies to humans by biting. If there is no proper management after getting a bite by rabid animal, one might further develop rabies. The disease can result in serious neurological problem and death is the end result. The best way is prevention of disease by postexposure prophylaxis against rabies. The effect of rabies on the renal system is little mentioned in the literature. The renal organ might be seriously affected by infection and acute kidney injury might occur. In addition, the rabies virus is transmittable by organ transplantation. Hence, there is a possible risk for renal transplant recipients to get rabies from a donor if there is no good preventive measure. Regarding rabies immunization, the use of vaccination for patients with the underlying renal failure is interesting. In this short article, the authors summarize on those important clinical issues of rabies and renal failure.
Nephropathology and Renal Manifestation of Rabies
Rabies mainly causes neurological manifestation. The classical pathognomonic presentation is hydrophobia. Patients usually end up with death. The nephro-pathology in rabies is little mentioned. Daher Ede et al reported an autopsy study on cases with rabies regarding the observation on renal pathology. They observed acute kidney injury in three out of six rabies cases. The damage can be seen in the glomerulus or renal tubule. The authors also found that “mild-to-moderate glomerular congestion and mild-to-intense peritubular capillary congestion” are common pathological findings in the kidney. In their report, two cases also had acute tubular necrosis. Hence, there is evidence that there might be renal pathology in rabies. Renal manifestation in rabies is an interesting clinical issue. As already noted, rabies is classified as a neurological disease. Renal manifestation is usually not observed. The pathophysiology of rabies resulting in acute kidney injury might be the direct damage to glomerulus and renal tubule. However, according to the report from Brazil, a tropical country with high prevalence of rabies, one-third of the patients have evidence of acute kidney injury. Daher Ede et al proposed that hydrophobia, dehydration, and neurological dysfunction might be the etiology of renal failure in rabies patients.
Rabies and Kidney Transplantation
Kidney transplantation is the standard management for end-stage renal disease. There is a possibility of rabies transmission due to solid organ transplantation. There are some case reports from transplantation centers in America., The transmission of rabies from a single organ donor to four transplant recipients, including kidney recipients, is an interesting case., Within one month after transplantation, all transplant recipients developed rabies, and the root cause analysis showed the previously underdiagnosed rabies in the donor., Recent reports from China confirm kidney transplantation-related rabies. In that reports, two confirmed cases of kidney receipts from a same donor developed rabies within one month after transplantation and died. In all the reported cases, the clinical history of exposure to at-risk animals, such as bat, of organ donors, is usually derived by the disease investigation team. Recently, there is also a report from Kuwait on a case of rabies acquired through kidney transplantation in a child. It is suggested that rabies screening in donated organ might be necessary in any countries where rabies is common. For non-endemic countries, donor from endemic country or with a history of travel to endemic country and with unclear cause of death should be avoided. Careful checking for the history of exposure to at-risk animal of the donor before transplantation is also necessary.
Rabies Immunization in Dialysis patients and Kidney Transplant Recipients
Exposure to at-risk animal is very common in tropical developing countries. It is no doubt that a renal failure patient might get bite by an animal and requires postexposure rabies immunization. The effectiveness and safety of rabies vaccination among patients with chronic kidney disease is an interesting clinical issue. In general, rabies vaccination is proven safe, and there is no report on the renal side effect after vaccination in the general population. Based on the authors’ experience in medical centers in Thailand, rabies vaccination for patients with the underlying chronic kidney disease is safe and results in no serious side effect. Focusing on the effectiveness and safety of rabies vaccination in patients with end-stage kidney disease on hemodialysis, it is proven that the vaccination is safe according to a report from Thailand. According to that Thai report, a good immune response from standard rabies vaccination regimen can be observed. Tanisaro et al studied immune response to rabies vaccination in hemodialysis patients and found that the immune responses in all patients were above the acceptable level for rabies protection.
Focusing on kidney recipients, the standard postexposure rabies vaccination is also proven effective and safe. Similar to the general public, the kidney recipient has a chance to get bitten by at-risk animal. The use of post exposure immunoprophylaxis is required in this scenario. There is also no effect from immunosuppressive therapy on immune response to rabies vaccination among kidney recipients. Rabies immunoglobulin has also proven to be safe for use in kidney recipients. There is a recent report on using immuno-prophylaxis against rabies in kidney recipients due to the risk of receiving organ from donor with rabies. In that report, the donor was proven to have rabies, but the kidney transplantation process was already done. The transplantation medicine team decided to start standard rabies immunoprophylaxis to recipients, and the kidney recipient still has no rabies for at least 36 months on follow-up. In another case, a more interesting situation has been reported. In a case of transplantation-related rabies in a kidney transplantation, the patient end up with death, and the disease investigation confirmed the evidence of raccoon rabies virus infection. Immunoprophylaxis was administered to other organ recipients receiving other organs from the same donor as the indexed dead kidney recipient and the other organ recipients still developed no rabies.
Finally, renal side effects of rabies immunization should be mentioned. Although rabies vaccination is considered safe, there is an interesting rare case of glomerulonephritis after immunization with anti-rabies vaccine. This phenomenon is believed to be due to hypersensitivity., The pathogenesis might be the excessive immune stimulation resulting in the production of pathogenic immune complex.
Rabies is an important tropical infection. Renal problem in rabies is possible but little mentioned. Rabies might induce glomerular and renal tubular disorder. Rabies might be transmitted to renal transplant recipients if there is no good donor screening. Regarding the postexposure immunoprophylaxis against rabies in patients with renal problem, standard rabies vaccination is proven to be effective and safe.
Conflict of interest: None declared.
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