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 ~  Abstract
 ~  Materials and Me...
 ~  Results
 ~  Discussion
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Year : 2002  |  Volume : 20  |  Issue : 1  |  Page : 47-49
 

Opportunistic infections following renal transplantation


Dept. of Microbiology, Medwin Hospitals, Raghava Ratna Towers, Chirag Ali Lane, Hyderabad - 500 001, India

Correspondence Address:
Dept. of Microbiology, Medwin Hospitals, Raghava Ratna Towers, Chirag Ali Lane, Hyderabad - 500 001, India

 ~ Abstract 

Opportunistic infection is common following renal transplantation. Prompt diagnosis and management can be life saving. Four different types of opportunistic respiratory infections diagnosed at our center during the period of January 1998 to December 2000 are discussed. Of the four cases one had Aspergillus, second had Sporothrix, third had Nocardia and fourth case Actinomyces species. Microbiologist has an important role to play by being aware of such opportunistic infections and helping the clinician to make early aetiological diagnosis.

How to cite this article:
Rao K H, Jha R, Narayan G, Sinha S. Opportunistic infections following renal transplantation. Indian J Med Microbiol 2002;20:47-9


How to cite this URL:
Rao K H, Jha R, Narayan G, Sinha S. Opportunistic infections following renal transplantation. Indian J Med Microbiol [serial online] 2002 [cited 2019 Jun 18];20:47-9. Available from: http://www.ijmm.org/text.asp?2002/20/1/47/8342


Opportunistic infections are common after renal transplantation. Modification of clinical manifestation of infection by immunosuppressive therapy is a major problem leading to delayed recognition.[1] Infection is documented in more than 2/3 of transplants in first year and remains a leading cause of death at all points in post transplant course.[2] Urinary tract infection ranks first followed by pulmonary infection. Pulmonary infection is a serious complication following kidney transplantation.[3],[4] Though over all incidence and mortality of pneumonia has decreased with judicious use of immunosuppressive therapy and more aggressive treatment,[5] it still is a major problem in developing countries.[6],[7] We highlight our experience in this regard of diagnosis of relatively less common and under diagnosed opportunistic infection in last three years from January 1998 to December 2000 in cases of renal transplantation.

 ~ Materials and Methods Top

During the period of January 1998 to December, 2000, 40 renal transplant surgeries were done at our center. Four different kinds of respiratory infections were diagnosed with follow up ranging from 1 month to 1 year post renal transplant at the time of infection. All the patients were on triple drug immunosuppression (cyclosporin, azathioprine, prednisolone) and also on isoniazide cum co-trimoxazole prophylaxis. Samples analyzed were CT guided material, nasopharyngeal biopsy, sputum and pleural effusion. Methods used were conventional. Direct microscopy was done in 10% KOH mount, lactophenol cotton blue and wherever indicated Gram stain and modified (1% H2SO4) AFB stain were performed. Samples were inoculated on to Sabouraud dextrose agar (SDA), blood agar, brain heart infusion agar, chocolate agar. SDA was incubated at two different temperatures (37C and 25C) for dimorphic fungi. Media were observed for growth every week, and aetiological identity was established with direct microscopy, staining, and growth characteristics.

 ~ Results Top

The diagnosis of opportunistic infection was based on clinical features, profile of infection, imageology, culture characteristics and microscopic morphology of the isolated fungus. Microbiological diagnosis was the basis of final diagnosis in all the four cases. Histopathologic confirmation was obtained only in one case (Sporothrix schenkii). Appropriate treatment was given in all four cases. Three of them succumbed to infection and one survived [Table - 1].

 ~ Discussion Top

In transplant recipients a wide range of microorganisms cause pulmonary sepsis. In the first post operative month, bacterial pneumonias predominate. Two to four months after transplantation pneumonias are caused by both opportunistic and bacterial pathogens.[9] Aspergillus fumigatus and Candida spp. are the most common fungal agents. Pneumonia due to Nocardia spp. is uncommon but not rare. Actinomycotic lung infection is distinctly rare.
Of the four opportunistic cases seen in the last three years, one patient was seen in the first month of renal transplantation, which is quite uncommon. As Aspergillosis occurring within one month is very rare, surveillance cultures from AC ducts was done that came positive for Aspergillus spp. After taking care of this hospital acquired exposure hazards, there has been no incidence of Aspergillus infections. Such nosocomial outbreaks of Aspergillosis are well recognized complications of construction work near hospital in which neutropenic patients are housed.[10]
An earlier study of 8 years, at the same hospital, analyzed the incidence of pulmonary infections after kidney transplant (27 / 142 =19%).11 The aetiological spectrum was diverse (TB in 10, gram negative infection in 2, gram positive infection, mixed bacterial and fungal infection in 4, Pneumocystis in 2, unconfirmed infection in 4, Nocardia in 2, Aspergillus fumigatus in 2). In this earlier study, 11 out of 27 patients had died. In the present study, 4/40 transplant patients (10%) got opportunistic infection and 3 of them died despite appropriate antifungal treatment There were no other pulmonary infections in these 40 patients probably because of INH and co-trimoxazole prophylaxis, which were given for the prevention of for TB and Pneumocystis infections respectively.
In conclusion, pulmonary infections continue to be a common complication of immunosuppression with high mortality as seen by earlier study and the current report, Increased awareness and aggressive approach is required to prevent such infections. Earlier study and the present study, highlight that these unusual / opportunistic lung infections in post transplant period are becoming common because of increasing number of transplants and better diagnostic facilities.
Clinical and Radiologic parameters have poor predictive value in identifying the microbiological nature of respiratory tract infections in the post transplant patients. A wide range of microorganisms can be present with similar findings in immunosuppresed patients. Microbiological identification of the aetiology is therefore mandatory. Early diagnosis by appropriate stain / culture can help the clinicians to save such patients, who otherwise invariably succumb to these infections. We also recommend, based on our experience, to be vigilant about nosocomial exposure risk (to Aspergillus / Nocardia ) by periodic sampling of AC ducts in the transplant room, operation theater and dialysis units and also to obtain appropriate samples for detailed microbiological diagnosis at the earliest. The microbiologist also needs to be conversant of uncommon pathogens for helping the clinicians to manage these life threatening infections. 

 ~ References Top

1.Carpenter CB, Lazarus MJ. Dialysis and Transplantation in the treatment of renal failure.In: Harrison's principles of internal medicine 11th ed.volume II, Braunwald, Isselbacher, Petersdorf, Wilson , Martin, Fauci Eds, (Mc Graw Hill book company) 1987: 1169   Back to cited text no. 1    
2.Rubin RH: Infection in renal and liver transplant patient. In: Clinical approach to infection in the compromised host. 4th ed. Rubin RH:, Young LS Eds (New York NY, Plenium) 1988: 557-621.   Back to cited text no. 2    
3.Edelstein CL, Jacobs JC Moosa CR.Pulmonary complications in 110 consecutive renal transplant recipients. SAMJ 1995; 85: 160-165.   Back to cited text no. 3    
4.Munda R, Aleander JW, First MR Gratside PS Fidler JP Pulmonary infection in renal transplant recipient. Annals of Surgery 1978; 187 (2):126-133.   Back to cited text no. 4    
5.Sia Irene G., Paya Carlos V. Infections complications following renal transplantation: Surg Clin N Amer 1998; 78 (1): 95-112.   Back to cited text no. 5    
6.Sharma RK Malhotra KK, Bhuyan VN, Dash SC, Kumar R, Dhawan IK. Infection in renal transplant recipient. JAPI 1985; 33: 757-761.   Back to cited text no. 6    
7.Desai JD Jadav S, Rai HP, Almedia A, Acharya VN, Morbidity and motality due to infection is renal allograft recipient - a study of 100 cases. Indian J Neph1992; 2: 245-248   Back to cited text no. 7    
8.Luo W. Pulmonary infections in renal transplant recipient. Chung Hua 1 Hsueh Tsa chih (Taipei) 1991; 71: 246-248.  Back to cited text no. 8    
9.Eleanor LR, Nicholas LT, Mark DR. Clinical aspects of renal transplantation. In: The Kidney, Vol 2; Brenner and Rector Eds.; (WB Saunders) 1991: 2380- 2384.   Back to cited text no. 9    
10.SessA,Meroni M, Battnene G, Pitengolo F, Giordan F, Marks M.Casselle P. Nosocomial out break of Aspergillus fumigatus infection among patients in renal unit. Nephrol Dial Transplant 1995; 11( 7): 1322-1324.   Back to cited text no. 10    
11.Jha R, Narayan G, Jaleel MA, Sinha S, Bhaskar V, Kashyap G. Pulmonary infections after kidney transplantation. JAPI 1999; 47( 8): 779-783.   Back to cited text no. 11    
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