Pulmonary Infections in Renal Transplant Recipients

Forty-six episodes of pulmonary infection occurred in 41 patients during a seven year period in which 187 renal transplants were performed in 168 patients. Thirty-seven episodes followed 152 cadaveric transplants (24.39%), and four episodes followed 35 living related donor transplants (11.4%). Five patients had two episodes of pulmonary infection. Twenty-four patients recovered, and 17 died (41.5%). Pulmonary infections appeared from two days to three years after transplantation, but predominated in the first four months (32/46). They were caused primarily by bacterial agents (74%) with protozoa, fungi, and viruses appearing less frequently. In 35 episodes, a single etiologic agent was found, but 11 were caused by two or more agents. When compared with noninfected recipients, there was no significant difference with regard to number of rejection crises, maintenance prednisone dosage, or blood glucose. However, subnormal renal function was significantly associated with the development of infection. Azathioprine dosages were actually higher for the noninfected patients, reflecting a tendency to lower the dose of azathioprine in the presence of decreased renal function. Fever was the most common presenting symptom. Transtracheal aspiration with Gram stain and direct sensitivity plating routinely provided early and accurate identification of the organism and a guide for therapy in bacterial infections. Pulmonary infection in renal transplant recipients is associated with a high mortality rate. Early diagnosis and specific treatment are essential to successful management.     

肾移植术后深部真菌感染10例报告

１９９１年１月－１９９３年１２月我所３３１例肾移植患者中发生深部真菌感染１０例，其中９例为念珠菌感染，１例为曲霉菌感染。经咪康唑或大扶康的正规治疗后，除１例发展为真菌性败血症死亡外，余９例感染治愈，但有３例移植肾因此丧失功能。我们认为肾移植术后应重视深部真菌感染问题，抗真菌药物以大扶康的首选。     

Blood Stream Infections in Renal Transplant Recipients: A Single-Center Study

IntroductionBacteremias among renal transplant recipients are more frequent as a result of immunosuppression. They are considered extremely high-risk because they are correlated with decreased allograft and recipient survival.Patients and MethodsAll episodes of bacteremia among renal transplant recipients were documented following review of medical records, from January 2010 to May 2013.ResultsIn total 26 episodes of bacteremia were observed in 22 patients. Gram negative bacteremia was identified in 73% (19/26) cases. Pathogens according to their frequency were the following Escherichia coli (6/26, 23%), Klebsiella pneumonia (5/26, 19%), Pseudomonas aeruginosa (3/26, 11%), Staphylococcus epidermidis (3/26, 11%), Acinetobacter baumanni (2/26, 7.7%), Enterococcus faecalis (2/26, 7.7%). The first trimester post renal transplantation 18 episodes (69%) of bacteremia were presented that were not correlated to indwelling urinary catheter or stent. Positive urinary culture with the same pathogen was recognized in 13 patients. All recipients manifested fever, eight recipients had leucocytosis and three cases were complicated by septic shock. Immediate resuscitation with intravenous fluids and non-nephrotoxic antibiotic regimen was initiated. Acute renal allograft dysfunction (defined as an increase in serum creatinine more than 0.5 mg/dL from baseline) was observed in five patients and was restored following infection resolution.ConclusionIncreased prevalence of bacteremia in renal transplant recipients is attributed to immunosuppression and usually bacteremic episodes follow urinary tract infection. The commonest pathogens are Gram negative bacteria with E. coli the most frequent. Early detection and proper management are important as bacteremia affects renal allograft and recipient survival.     

Viral Hepatitis Infections in Chronic Kidney Disease Patients and Renal Transplant Recipients

Within the last few decades, the incidence and prevalence of both hepatitis B and C infections have decreased among kidney disease patients. Significant advances have been made in the prevention of hepatitis B and C virus transmission in these high-risk populations; however, the transmission risk is still not negligible. Viral hepatitis infections represent a significant problem among kidney disease patients; patients on regular dialysis, as well as renal transplant recipients (RTRs) due to their epidemiological, virological, and clinical features. Chronic hepatitis B and C have a strong impact on the clinical course of kidney disease as well as on the clinical course after kidney transplantation. The purpose of this review is to focus on the epidemiology, transmission modes, natural courses, and treatment options of hepatitis B and C infections in both chronic kidney disease patients and RTRs.     

Pregnancy in Renal Transplant Recipients

Objective

Renal transplantation with a well-functioning graft leads to a rapid restoration of endocrine and sexual functions. The aim of this study was to examine our experience with pregnancies among renal transplant patients, particularly with regard to their impact on graft function.

Patients and Methods

We analyzed 10 pregnancies in 7 renal transplant recipients for long-term graft outcomes in terms of clinical and biological data.

Results

The mean patient age was 28.5 ± 4 years. They all received a living donor kidney. The time between transplantation and the onset of pregnancy was 33.4 ± 23.2 months. Regarding the immunosuppressive therapy, all patients received steroids and cyclosporine; 4 patients received in addition azathioprine and 2 received mycophenolate mofetil that was changed at 1 month before conception to azathioprine. There was no significant difference between the serum creatinine before and during pregnancy. We did not observe any acute rejection episode. Pregnancy complications were preclampsia in 1 case, hypertension in 1 case, urinary tract infection in 2 cases, and anemia in 80% of patients during the third trimester. Premature rupture of membranes occurred in 1 case and preterm delivery in 2 cases. Two cases of neonatal death were registered. Cesarean section was performed in 50% of cases. The follow-up revealed 2 cases of chronic rejection.

Conclusion

A multidisciplinary approach is necessary for pregnancy which generally occurs at 2 years after kidney transplantation.     

Demodicosis in Renal Transplant Recipients

Solid organ transplant recipients have an increased incidence of skin infections resulting from immunosuppression. Common pathogens include herpes simplex virus, varicella zoster virus, Gram‐positive bacteria and dermatophytes; however, the contribution of multicellular parasitic organisms to dermatologic disease in this population remains less studied. Demodex folliculorum and brevis are commensal mites that reside on human skin. Proliferation of Demodex mites, or demodicosis, is associated with rosacea and rosacea‐like disorders, particularly in immunocompromised populations, although their ability to cause disease is still the subject of debate. We present a case series of four renal transplant recipients with the singular chief complaint of acne rosacea who we diagnosed with demodicosis. Although one of the four patients showed complete resolution following initial antiparasitic therapy, the other three required subsequent antibacterial treatment to fully resolve their lesions. We suggest that demodicosis may be more prevalent than once thought in solid organ transplant recipients and showed that Demodex‐associated acne rosacea can be effectively treated in this population.     

Invasive Fungal Infections in Low-Risk Liver Transplant Recipients: A Multi-Center Prospective Observational Study

Prevention of invasive fungal infections (IFIs) in orthotopic liver transplant (OLT) recipients utilizing postoperative systemic antifungal prophylaxis, typically with fluconazole, is justified among those at high risk for IFI. Use of postoperative antifungal prophylaxis for low-risk OLT recipients is widely practiced but not universally accepted nor supported by data. We conducted a prospective observational study among 200 OLT recipients who were at low risk for IFI and did not receive postoperative antifungal prophylaxis. Patients were considered low risk if they had /=units of 40 blood products or return to the operating room for intra-abdominal bleeding; return to the operating room for anastomotic leak or vascular insufficiency; preoperative serum creatinine of >/=2 mg/dL; and perioperative Candida colonization. Patients were followed 100 d post-transplantation for evidence of IFI. Of 193 eligible patients, 7 (4%) developed an IFI. Three (2%) IFIs were due to Candida spp. and potentially preventable by standard fluconazole prophylaxis. Three patients developed invasive aspergillosis; one developed late onset disseminated cryptococcosis. Liver transplant recipients at low risk for IFI can be identified utilizing pre-determined criteria, and post-transplantation antifungal prophylaxis can be routinely withheld in these patients.     

Emerging Issues With Diagnosis and Management of Fungal Infections in Solid Organ Transplant Recipients

Invasive fungal infections (IFIs) are being increasingly recognized in solid organ transplant (SOT) recipients, and delayed diagnosis can lead to graft loss and death. Therefore, there is a low threshold for prophylaxis and early initiation of empiric antifungal treatment, in this patient population. Meanwhile, the increasing consumption of antifungals is associated with high cost, medication toxicities and the emergence of resistance in Candida species, all of which call for rational use of antifungal agents. The implementation of fungal biomarkers, molecular diagnostic methods and direct detection of volatile fungal metabolites in breath samples could lead to faster diagnosis, early appropriate treatment and improved clinical outcomes, but also aid in the de‐escalation of antifungal treatment. Those novel diagnostic modalities need to be validated specifically in SOT recipients. Infectious diseases consultation can contribute to optimization of care through prompt initiation and appropriate modification of antifungal treatment, management of medication toxicities and drug‐drug interactions, as well as source control. In this review, we conceptually summarize recent advances in the diagnosis and management of IFI in SOT recipients, and highlight the importance of early diagnostic tools and good stewardship of antifungal drugs.     

Hyperhomocysteinemia in Renal Transplant Recipients

Renal transplantation is a commonly performed curative procedure for end-stage renal disease. With the increase in renal allograft half-lives, attention is now being focused on cardiovascular morbidity and death in the renal transplant recipient (RTR) population. Among the more novel cardiovascular disease (CVD) risk factors for which this group is at risk is hyperhomocysteinemia. Hyperhomocysteinemia has been associated with an increased risk of CVD, although prospective randomized trials designed to prove causality are still ongoing. Since plasma total homocysteine levels are inversely related to renal function, RTRs have a greatly increased prevalence of hyperhomocysteinemia. Other determinants of homocysteine include B-vitamins, albumin, age, and genetic polymorphisms. Although RTRs are resistant to the typical B-vitamin doses used to correct hyperhomocysteinemia in the general population, they do respond to supraphysiologic dose therapy. In terms of prevalence, etiology, and treatment of hyperhomocysteinemia, RTRs are very similar to the much larger chronic renal insufficiency population. For this reason, RTRs have been chosen as an ideal study population in investigating the effect of reducing hyperhomocysteinemia on CVD outcomes.     

Post Transplant Erythrocytosis in Hypercalcemic Renal Transplant Recipients

In vitro data suggest that calcium plays an important role in normal and disordered erythropoiesis. The purpose of this study is to determine whether there is an association between serum calcium, various hormone levels, and the development of post transplant erythrocytosis (PTE). Data were collected on 283 patients who underwent renal transplantation between 1994 and 1998. The relationship between serum calcium and PTE development was tested using the chi-square test. Univariate and multivariable adjusted models were employed to determine predictors of maximum hematocrit. Selected patients underwent measurement of intact parathyroid hormone (PTH), 1,25-dihydroxy vitamin D, and erythropoietin (EPO). Seventy-three patients (26%) developed PTE. Post transplant erythrocytosis was more common in patients with hypercalcemia compared with patients with normal serum calcium (34% vs. 18%, p = 0.002). In multivariable analyses, serum calcium was a strong independent predictor of maximum hematocrit post transplant, even after adjustment for renal function. A serum calcium of >or=10.2 mg/dL was associated with greater than two-fold increased odds of PTE. There were no differences in hormone levels between subjects with hypercalcemia and PTE, subjects with PTE alone, and subjects with hypercalcemia alone. Hypercalcemia is associated with the development of PTE in renal transplant recipients.     

Chickenpox in Adult Renal Transplant Recipients

Five of 610 adults developed chickenpox between 35 days and9.2 years after renal transplantation, and only one patientsurvived. All patients received prednisolone and azathioprineduring the incubation period. Corticosteroid therapy was continued,but azathioprine was stopped after diagnosis. Four patientswere treated with acyclovir, but three were given suboptimaldoses. The patient who survived had been taking the lowest doseof azathioprine and was given the recommended dose of acyclovir.All patients who died developed disseminated intravascular coagulation,and at postmortem examination were found to have had cerebralhaemorrhage. None of the patients treated with acyclovir hadevidence of active varicella-zoster virus infection at postmortem examination, but two had disseminated bacterial and fungalinfections. Chickenpox follows a severe and often fatal course in adultswith renal transplants. Prompt acyclovir therapy can be effective,provided an adequate dose is given. Attention should be directedtowards prevention by the identification and immunisation ofat risk patients prior to transplantation.     

Paradoxical Depression in Renal Transplant Recipients

Paradoxical depression occurs despite a completely successful transplantation without tissue rejection or other medical complications. In this study, the occurrence of paradoxical depression was retrospectively investigated among 1139 Japanese successful renal transplant recipients January 1997 through September 2006. Among the 1139 recipients, 103 visited the Department of Psychiatry after renal transplantation, including 40 with depressive symptoms and 15 with a physical problem considered to have nonparadoxical depression. The other 25 recipients were considered to have paradoxical depression; that is, more than half of the 40 recipients with depressive symptoms had paradoxical depression. There were no significant differences in the clinical characteristics, including average age at the time of renal transplantation, rate of living-donor transplantation, rate of ABO incompatibility, method of dialysis (hemodialysis or peritoneal dialysis), duration of dialysis, and time interval between the renal transplantation and the initial visit to the Department of Psychiatry among the 2 groups. These results suggested that there was another risk factor or interactions between factors. Of the 25 recipients, 6 had relationship problems, 6 had social-rehabilitation problems, and 13 had mentioned no clear psychological problems. These psychological factors might in fact be related to the loss of an imagined past. Additional consecutive prospective studies are needed—a challenging prospect for consultation liaison psychiatrists in the field of transplantation.     

Invasive Pneumococcal Infections in Adult Lung Transplant Recipients

An increased risk of invasive pneumococcal infection (IPI) has been described among kidney or heart transplant recipients, but the epidemiology of IPI among lung transplant recipients has not been previously reported. We undertook a single center, retrospective cohort study to define the incidence, timing, clinical, and microbiologic features of IPI in lung transplant patients. Fourteen out of 220 recipients (6.4%) developed IPI at a median of 1.3 years after transplantation (incidence rate: 22.7 cases per 1000 person-years). All patients were receiving trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis at the time of diagnosis, and 10 (71%) had TMP-SMX-resistant isolates. All isolates were from the 23 valent polysaccharide vaccine-associated serogroups. The high incidence of IPI in lung transplant recipients is similar to that reported in kidney and heart recipients. Alternative prevention strategies, including use of the conjugated pneumococcal vaccine, should be explored in future studies.     

Transitional Cell Carcinoma in Renal Transplant Recipients

Renal transplantation (RTx) recipients have a high incidence of cancer, including transitional cell carcinoma (TCC). Posttransplantation urologic malignancies still present a challenge for transplant surgeons. Using the Dialysis and Transplant Registry of Taichung Veterans General Hospital, a total of 55 cancers were diagnosed in 52 RTx recipients between May 1983 and September 2001. Of these, 24 RTx recipients developing TCC were identified and presented the distinctly high percentage (43.6%) of TCC that were malignancies after RTx in Taiwan. The mean time between transplantation and initial diagnosis was 46 months in our series. Painless hematuria with pyuria is the most common mode of presentation. Transitional cell carcinoma of RTx recipients had multiple foci. Moreover, synchronous TCC in bilateral upper urinary tracts were confirmed in 9 (41%) recipients. The pathologic status of disease is invasive at diagnosis (pTa: 2, pT1: 7, pT2: 4, pT3: 6, pT4: 2, graft metastasis: 1 and distant metastasis: 2). Disseminated metastasis occurred in 6 recipients, all of whom died of their disease within 16 months. Five recipients received adjuvant chemotherapy and retained stable renal function. We conclude that RTx recipients have a markedly increased incidence of TCC in Taiwan, and that prophylactic bilateral nephroureterectomy of native kidneys with bladder cuff excision can be performed simultaneously in RTx recipients with TCC.     

Mobile Technology Affinity in Renal Transplant Recipients

Background

Medication nonadherence is a common problem in renal transplant recipients (RTRs). Mobile health approaches to improve medication adherence are a current trend, and several medication adherence apps are available. However, it is unknown whether RTRs use these technologies and to what extent. In the present study, the mobile technology affinity of RTRs was analyzed. We hypothesized significant age differences in mobile technology affinity and that mobile technology affinity is associated with better cognitive functioning as well as higher educational level.

Vitamin D Status in Renal Transplant Recipients

Vitamin D plays an important role in calcium homeostasis. Renal transplant recipients may be more susceptible to reduced levels because of decreased sun exposure and steroid therapy. This study aimed to determine vitamin D status after renal transplantation and its effect on parathyroid hormone (PTH) and bone mineral density (BMD). We measured serum 25-hydroxyvitamin D levels (25-OHD) in 244 renal transplant recipients, divided into two groups, 104 recently transplanted (less than 1 year) and 140 long-term. Vitamin D status was defined according to NKF/KDOQI guidelines. Mean 25-OHD levels were 33 +/- 19 nmol/L and 42 +/- 20 nmol/L, respectively, for the recent and long-term transplant recipients. Vitamin D insufficiency was present in 29% and 43%, deficiency in 56% and 46% and severe deficiency in 12% and 5%, respectively. An inverse correlation was found between logPTH and 25-OHD (r=-0.2, p= 0.019) in long-term but not in recently transplanted patients. No correlation was found between 25-OHD levels and BMD. Hypercalcaemia was present in 40% of the recently transplanted recipients and 25% of the long-term. In conclusion 25-OHD was low in virtually all of our renal transplant recipients and may aggravate secondary hyperparathyroidism, but its correction may be difficult in patients with hypercalcaemia.