Post-transplant infections: An ounce of prevention

Posttransplant complications: molecular mechanisms and therapeutic interventions

Posttransplantation complications pose a major challenge to the long-term survival and quality of life of organ transplant recipients. These complications encompass immune-mediated complications, infectious complications, metabolic complications, and malignancies, with each type influenced by various risk factors and pathological mechanisms. The molecular mechanisms underlying posttransplantation complications involve a complex interplay of immunological, metabolic, and oncogenic processes, including innate and adaptive immune activation, immunosuppressant side effects, and viral reactivation. Here, we provide a comprehensive overview of the clinical features, risk factors, and molecular mechanisms of major posttransplantation complications. We systematically summarize the current understanding of the immunological basis of allograft rejection and graft-versus-host disease, the metabolic dysregulation associated with immunosuppressive agents, and the role of oncogenic viruses in posttransplantation malignancies. Furthermore, we discuss potential prevention and intervention strategies based on these mechanistic insights, highlighting the importance of optimizing immunosuppressive regimens, enhancing infection prophylaxis, and implementing targeted therapies. We also emphasize the need for future research to develop individualized complication control strategies under the guidance of precision medicine, ultimately improving the prognosis and quality of life of transplant recipients.

Descriptive study on risk of increased morbidity of schistosomiasis and graft loss after liver transplantation

Solid-organ transplantation procedures have witnessed a surge in frequency. Consequently, increased attention to associated infections and their impact on graft success is warranted. The liver is the principal target for infection by the flatworm Schistosoma mansoni. Hence, rigorous screening protocols for this parasite should be implemented for liver transplantation donors and recipients. This study investigated the risks posed by schistosomiasis-infected liver tissues for successful liver transplantation (LT), considering donors and recipients, by analyzing reported cases. Among the 43 patients undergoing LT (donors = 19; recipients = 24), 32 were infected with S. mansoni, five were infected with other Schistosoma species, and no identification was made in four patients. Reported follow-up periods ranged from 1 to 132 months, and all patients achieved successful recovery. As these helminths do not replicate in their vertebrate hosts, immunosuppressive treatment is not expected to promote increased morbidity or reactivation. Moreover, suspected or confirmed schistosomiasis infections often have a benign course, and generally, should not prevent LT. The available literature was reviewed and a provisional screening protocol has been proposed.

The Predictors and Risk Factors of 2-Year Rejection in Renal Transplant Patients: A Multicenter Case-Control Study

INTRODUCTION

Kidney transplantation is a definitive treatment for end-stage renal disease. It is associated with improved life expectancy and quality of life. One of the most common complications following kidney transplantation is graft rejection. To our knowledge, no previous study has identified rejection risk factors in kidney transplant recipients in Saudi Arabia. Therefore, this study aimed to determine the specific risk factors of graft rejection.

METHODS

A multicenter case-control study was conducted at four transplant centers in Saudi Arabia. All adult patients who underwent a renal transplant between January 1, 2015 and December 31, 2021 were screened for eligibility. Included patients were categorized into two groups (cases and control) based on the occurrence of biopsy-proven rejection within 2 years. The primary outcome was to determine the risk factors for rejection within the 2 years of transplant. Exact matching was utilized using a 1:4 ratio based on patients' age, gender, and transplant year.

RESULTS

Out of 1,320 screened renal transplant recipients, 816 patients were included. The overall prevalence of 2-year rejection was 13.9%. In bivariate analysis, deceased donor status, the presence of donor-specific antibody (DSA), intraoperative hypotension, Pseudomonas aeruginosa, Candida, and any infection within 2 years were linked with an increased risk of 2-year rejection. However, in the logistic regression analysis, the presence of DSA was identified as a significant risk for 2-year rejection (adjusted OR: 2.68; 95% CI: 1.10, 6.49, p = 0.03). Furthermore, blood infection, infected with Pseudomonas aeruginosa or BK virus within 2 years of transplant, were associated with higher odds of 2-year rejection (adjusted OR: 3.10; 95% CI: 1.48, 6.48, p = 0.003, adjusted OR: 3.23; 95% CI: 0.87, 11.97, p = 0.08 and adjusted OR: 2.76; 95% CI: 0.89, 8.48, p = 0.07, respectively).

CONCLUSION

Our findings emphasize the need for appropriate prevention and management of infections following kidney transplantation to avoid more serious problems, such as rejection, which could significantly raise the likelihood of allograft failure and probably death. Further studies with larger sample sizes are needed to investigate the impact of serum chloride levels prior to transplant and intraoperative hypotension on the risk of graft rejection and failure.

Hypoalbuminemia is a risk factor for invasive fungal infections and poor outcomes in infected kidney transplant recipients

INTRODUCTION

Invasive fungal infections (IFI), are estimated to occur in 2%-14% of kidney transplant recipients (KTRs) in the current era of immune suppression and are associated with high mortality rates. We hypothesized that hypoalbuminemia in KTRs is a risk factor for IFI and would be associated with poor outcomes.

METHODS

In this study, using data from a prospective cohort registry, we describe the frequency of IFI due to Blastomycosis, Coccidioidomycosis, Histoplasmosis, Aspergillosis, and Cryptococcus in KTRs with serum albumin levels measured 3-6 months before diagnosis. Controls were selected based on incidence density sampling. KTRs were divided into three groups based on the pre-IFI serum albumin level: normal (≥4 g/dL), mild (3-4 g/dL), or severe (<3 g/dL) hypoalbuminemia. Outcomes of interest were uncensored graft failure after IFI and overall mortality.

RESULTS

A total of 113 KTRs with IFI were compared with 348 controls. The incidence rate of IFI among individuals with normal, mild, and severe hypoalbuminemia was 3.6, 8.7, and 29.3 per 100 person-years, respectively. After adjustment for multiple variables, the trend for risk of uncensored graft failure following IFI was greater in KTRS with mild (HR = 2.1; 95% CI, .75-6.1) and severe (HR = 4.47; 95% CI, 1.56-12.8) hypoalbuminemia (P-trend < .001) compared to those with normal serum albumin. Similarly, mortality was higher in severe hypoalbuminemia (HR = 1.9; 95% CI, .67-5.6) compared to normal serum albumin (P-trend < .001).

CONCLUSION

Hypoalbuminemia precedes the diagnosis of IFI in KTRs, and is associated with poor outcomes following IFI. Hypoalbuminemia may be a useful predictor of IFI in KTRs and could be incorporated into screening algorithms.

Gut Microbiota-Mediated Pharmacokinetic Drug-Drug Interactions between Mycophenolic Acid and Trimethoprim-Sulfamethoxazole in Humans

Mycophenolic acid (MPA) and trimethoprim-sulfamethoxazole (TMP-SMX) are commonly prescribed together in certain groups of patients, including solid organ transplant recipients. However, little is known about the pharmacokinetic drug-drug interactions (DDIs) between these two medications. Therefore, the present study aimed to determine the effects of TMP-SMX on MPA pharmacokinetics in humans and to find out the relationship between MPA pharmacokinetics and gut microbiota alteration. This study enrolled 16 healthy volunteers to take a single oral dose of 1000 mg mycophenolate mofetil (MMF), a prodrug of MPA, administered without and with concurrent use of TMP-SMX (320/1600 mg/day) for five days. The pharmacokinetic parameters of MPA and its glucuronide (MPAG) were measured using high-performance liquid chromatography. The composition of gut microbiota in stool samples was profiled using a 16S rRNA metagenomic sequencing technique during pre- and post-TMP-SMX treatment. Relative abundance, bacterial co-occurrence networks, and correlations between bacterial abundance and pharmacokinetic parameters were investigated. The results showed a significant decrease in systemic MPA exposure when TMP-SMX was coadministered with MMF. Analysis of the gut microbiome revealed altered relative abundance of two enriched genera, namely the genus Bacteroides and Faecalibacterium, following TMP-SMX treatment. The relative abundance of the genera Bacteroides, [Eubacterium] coprostanoligenes group, [Eubacterium] eligens group, and Ruminococcus appeared to be significantly correlated with systemic MPA exposure. Coadministration of TMP-SMX with MMF resulted in a reduction in systemic MPA exposure. The pharmacokinetic DDIs between these two drugs were attributed to the effect of TMP-SMX, a broad-spectrum antibiotic, on gut microbiota-mediated MPA metabolism.

Seroprevalence of Cytomegalovirus in Haemodialysis Patients

Cytomegalovirus (CMV) is prevalent worldwide. It belongs to the β-herpesvirinae subfamily of Herpesviridae and comprises a double-stranded linear DNA genome and capsid, surrounded by an envelope. CMV infection is most prominently found in patients with kidney failure caused by various possible reasons such as urinary tract infection or systemic disease and are undergoing dialysis. The present study was conducted during the period of March 2020 to April 2021. It included 96 patients with chronic kidney disease undergoing hemodialysis (44 of patients were women and 52 men) within the age range of 11-70 years. Five-mL of the venous blood sample was drawn from each patient to conduct the rapid antibody test for the presence of CMV-specific antibodies (both IgG, and IgM). This study showed that the seroprevalence of CMV infection among haemodialysis patients was 75%. The seropositivity for CMV-IgG was 72.9% which was significantly higher than that for CMV-IgM (2.1%) for both sexes. The present study further demonstrated that the prevalence of positive CMV-IgG in males was higher than that in females (38.5% and 34.4%, respectively). In addition, the positivity of CMV-IgM was highest in the age group 61–70 years old (2.1%), while the positivity of CMV-IgG was highest in patients age groups 41–50 years (24%). The present study revealed a high seroprevalence of CMV infection among haemodialysis patients in Basrah City. The elevated seroprevalence could be related to many factors, including the endemicity of the virus, public health, patient immunity, environmental factors, and geographical location. CMV infection increases with age, and the infection rate in men was higher than that in women. The seroprevalence rate of CMV-IgG antibodies was higher than that of CMV-IgM antibodies, indicating a previous infection or reactivation of CMV virus among haemodialysis patients, leading to a high risk of CMV infection.

Post-CMV Organizing Pneumonia - An Unusual Presentation 10 years after Kidney Transplantation

A 45-year-old gentleman underwent kidney transplantation in March 2010. He remained apparently healthy for the next 10 years when he developed anorexia and weight loss. Diagnostic workup revealed cytomegalovirus (CMV) pneumonia. While viremia resolved within 3 weeks of initiation of valganciclovir, he developed progressive breathlessness and hypoxia on exertion. Imaging of thorax revealed central peri-bronchovascular consolidation and fine reticulations with peripheral sparing. Computed tomography (CT)-guided percutaneous lung biopsy revealed organizing intra-alveolar exudates, suggestive of organizing pneumonia, with no evidence of active infection on biopsy as well as bronchoalveolar lavage (BAL) cytology. This atypical pattern of central distribution of opacities is not typical of organizing pneumonia where peripheral subpleural distribution is more common. Patient responded dramatically following escalation of steroids, with complete resolution of infiltrates on follow-up imaging.

Effect of mycophenolic acid and tacrolimus on the incidence of infectious complications after kidney transplantation

INTRODUCTION

Infectious complications remain a common cause of mortality after kidney transplantation (KTx). Goal of effective immunosuppressive treatment (IS) must be balanced between decreasing incidence of acute kidney rejection (AKR) and avoiding the incidence of infections, at the same time.

MATERIALS AND METHODS

The aim of our analysis was to identify the risk of fixed daily dose (DD) of mycophenolic acid (MPA) and levels of tacrolimus (TAC) in the development of a single, recurrent infection and AKR after KTx.

RESULTS

Our analysis consisted of 100 patients after KTx (66 males, 34 females). MPA DD > 1080 mg was a risk factor (RF) for recurrent infection in general (OR 1.2964;P = 0.0277), for recurrent bacterial infection from 1^st to 6^th month (OR 1.2674;P = 0.0151), recurrent bacterial infection (OR 1.2574;P = 0.0436), single viral infection (OR 1.2640;P = 0.0398) from 6^th-12^th month after KTx. MPA DD > 1080 mg and levels of TAC above recommended levels were not independent RF for the incidence of the infection.

CONCLUSION

MPA DD > 1080 mg as a RF for recurrent infection starting in the 1^st month after KTx with significant association between the incidence of infections and MPA DD and TAC levels, without increased risk of AKR. In the centers with fixed dosing of IS, this can lead to lowering the risk of infections by decreasing MPA DD 1 month after KTx without increasing risk of infections.

Cell Therapy in Solid Organ Transplantation

Transplantation is the only cure for end-stage organ failure. Current immunosuppressive drugs have two major limitations: 1) non antigen specificity, which increases the risk of cancer and infection diseases, and 2) chronic toxicity. Cell therapy appears to be an innovative and promising strategy to minimize the use of immunosuppression in transplantation and to improve long-term graft survival. Preclinical studies have shown efficacy and safety of using various suppressor cells, such as regulatory T cells, regulatory B cells and tolerogenic dendritic cells. Recent clinical trials using cellbased therapies in solid organ transplantation also hold out the promise of improving efficacy. In this review, we will briefly go over the rejection process, current immunosuppressive drugs, and the potential therapeutic use of regulatory cells in transplantation.

Immunosuppressive Medication and Non-Rejection-Related Complications Following Heart Transplantation

Background: Although the clinical evolution of a patient with heart failure is initially improved by transplantation, a number of potential complications may occur in the post-transplant period, which may be directly related to the effects of chronic immunosuppression. The purpose of this study was to analyze the occurrence and frequency of post-transplant complications related to immunosuppressive treatment in the Institute of Cardiovascular Diseases and Transplantation of Târgu Mureș, Romania.

Material and methods: This is a descriptive study including 53 patients out of a total of 71 patients who underwent cardiac transplantation between 2000 and 2017 in the Institute of Cardiovascular Disease and Cardiac Transplantation in Târgu Mureș, Romania. Data were collected from the patient files and included demographic, clinical and laboratory data, as well as information about post-transplant complications related to immunosuppressive treatment.

Results: The mean age of patients undergoing heart transplantation was 40.72 ± 14.07 years, the majority of patients being male (84.91%) and living in an urban environment (56.60%). The average length of hospital stay was 33.6 days. From the total number of patients, 7 (13.2%) presented post-transplantation bacterial infections, while antibodies indicating the presence or history of B hepatitis, toxoplasma, and cytomegalovirus infection were identified with a relatively high incidence in the study population.

Conclusions: Infections following surgery are probably the most common post-transplant pathology, the primary reason being the administration of immunosuppressive medication.

Immunosuppression following organ transplantation. Part 2: complications and their management

Advances in the care of patients who have had a solid organ transplant has led to a growing population of post-transplant patients, who are also living for longer. As a result of their longer life expectancy, transplant recipients often face a multitude of challenges, including optimising their immunosuppressive regimens and managing potential complications. Life-threatening infections, malignancies, and organ-specific toxicities are the complications post-transplant patients commonly encounter and these complications are often associated with increased morbidity and mortality, adverse graft functioning and survival, profound impairment in the patient's quality of life, and significant healthcare burden. This article, the second of two parts, gives an overview of the issues involved in the care of patients who are receiving immunosuppressants. The common complications encountered by post-transplant patients are discussed and their assessment, management, prevention and treatment explored.

Risk factors for complications and graft failure in kidney transplant patients with sepsis

Immunosuppressive therapies decrease the incidence of acute kidney rejection after kidney transplantation, but also increase the risk of infections and sepsis. This study aimed to identify the risk factors associated with complications and/or graft failure in kidney transplant patients with sepsis. A total of 14,658 kidney transplant patients with sepsis, identified in the National Inpatient Sample (NIS) database (data from 2005-2014), were included in the study and classified into three groups: patients without complications or graft failure/dialysis (Group 1), patients with complications only (Group 2), and patients with complications and graft failure/dialysis (Group 3). Multinomial logistic regression analyses were conducted to evaluate factors associated with kidney transplant recipients. Multivariate analysis showed that, compared to Group 1, patients from Group 2 or Group 3 were more likely to be Black and to have cytomegalovirus infection, coagulopathy, and glomerulonephritis (p ≤ 0.041). Also, Group 2 was more likely to have herpes simplex virus infection, and Group 3 was more likely to have hepatitis C infection and peripheral vascular disorders, compared to Group 1 (p ≤ 0.002). In addition, patients in Group 3 were more likely to be Black and to have hepatitis C infection, peripheral vascular disorders, coagulopathy, and hypertension compared to Group 2 (p ≤ 0.039). Age and female gender were associated with lower odds of complications after kidney transplantation regardless of graft rejection/dialysis (p ≤ 0.049). Hyperlipidemia and diabetes decreased the chance of complications and graft failure/dialysis after kidney transplant (p < 0.001). In conclusion, the study highlights that black race, male gender, and specific comorbidities can increase the risk of complications and graft failure in kidney transplant patients with sepsis.

BK viremia is not associated with adverse outcomes in the absence of BK nephropathy

There are limited data regarding the association of different levels of BK viremia and BK nephropathy (BKN), and graft outcomes. We studied the BK plasma PCR levels of all kidney transplant recipients (KTR) transplanted at our institution between 01/01/2006 and 06/30/2014. Patients were divided into groups based on their highest BK plasma PCR level within the first year following transplantation: undetectable, low (<1000 copies/mL), moderate (1000-10 000 copies/mL), high (>10 000-100 000 copies/mL), very high (>100 000 copies/mL), and those that had biopsy-proven BKN. There were a total of 1146 KTR during the study period: 813 with undetectable BK levels and 333 with any detectable BK level (87 with low, 79 with moderate, 88 with high, 34 with very high level BK, and 45 that had BKN). Compared to KTR with an undetectable BK level, incidence of mortality, graft failure, rejections,and infections were not significantly different for those with low, moderate, high, or very high BK level. Patients with BKN had a higher rate of infection and higher rates of total graft failure or death-censored graft failure compared to those with undetectable BK levels. BK viremia in the absence of BKN does not significantly increase the risk of rejection, infections, or graft failure compared to an undetectable BK level.

The feared five fungal infections in kidney transplant recipients: A single-center 20-year experience

Invasive fungal infections are a feared complication in kidney transplant recipients (KTRs). Here we present the University of Wisconsin experience with 5 invasive fungal infections-aspergillosis, cryptococcosis, histoplasmosis, blastomycosis, and coccidioidomycosis-in KTRs transplanted between 01/01/1994 and 06/30/2014. During this period, there were 128 cases of fungal infections; aspergillosis was the most common (72), followed by cryptococcosis (29), histoplasmosis (14), blastomycosis (10), and coccidioidomycosis (3). The mean interval from transplant to fungal infection was 3.19 ± 3.58 years (range 5 days-15.8 years). By 6 months postinfection, there were 53 (41%) graft failures and 24 (19%) deaths. Graft failure occurred in 46%, 38%, 21%, 40%, and 67% of patients with aspergillosis, cryptococcosis, histoplasmosis, blastomycosis, and coccidioidomycosis, respectively. Anti-thymocyte globulin (ATG) induction (HR, 1.49; 95% CI, 1.03-2.16; P = .04), diabetes (HR, 1.53; 95% CI, 1.05-2.21; P = .03), and age (HR, 1.47; 95% CI, 1.27-1.70; P ≤ .001) were associated with an increased risk for infection in univariate analysis. Multivariate adjustment retained ATG induction and older age. A large proportion of kidney transplant recipients with invasive fungal infections suffer graft failure within 3 years. Preventive, therapeutic, and monitoring strategies are needed to improve graft and patient outcomes.

In vitro intracellular IFNγ, IL-17 and IL-10 producing T cells correlates with the occurrence of post-transplant opportunistic infection in liver and kidney recipients

AIM

To validate intracellular cytokine production functional assay as means of cell-mediated immunity monitoring of post-transplant patients with opportunistic infection (OI).

METHODS

Intracellular cytokine-producing CD4⁺ and CD8⁺ T-cell monitoring was carried out in 30 liver transplant (LTr) and 31 kidney transplant (KTr) recipients from 2010 to 2012. Patients were assessed in our Department of Immunology at the Clinical University ‘Hospital Virgen de la Arrixaca-IMIB’ in Murcia, Spain for one year following transplantation. FACS Canto II flow cytometer was employed to quantify the intracellular production of IL-17, IFNγ and IL-10 cytokines on stimulated CD4⁺CD69⁺ and CD8⁺CD69⁺ T cells and BD FACS DIVA v.6 software was used to analysed the data. Statistical analysis was carried out using SPSS 22.0.

RESULTS

LTr with OI had significantly lower % of CD8⁺CD69⁺IFNγ⁺ T cells at 60 (7.95 ± 0.77 vs 26.25 ± 2.09, P < 0.001), 90 (7.47 ± 1.05 vs 30.34 ± 3.52, P < 0.001) and 180 (15.31 ± 3.24 vs 24.59 ± 3.28, P = 0.01) d post-transplantation. Higher % of CD4⁺CD69⁺IL-10⁺ as well as CD4⁺CD69⁺IL-17⁺ T cells were yet reported at 30 (14.06 ± 1.65 vs 6.09 ± 0.53, P = 0.0007 and 4.23 ± 0.56 vs 0.81 ± 0.14, P = 0.005; respectively), 60 (11.46 ± 1.42 vs 4.54 ± 0.91, P = 0.001 and 4.21 ± 0.59 vs 1.43 ± 0.42, P = 0.03; respectively) and 90 d (16.85 ± 1.60 vs 4.07 ± 0.63, P < 0.001 and 3.97 ± 0.43 vs 0.96 ± 0.17, P = 0.001). Yet, KTr with OI had significantly lower percentage of CD4⁺CD69⁺IFNγ⁺ at 30 (11.80 ± 1.59 vs 20.64 ± 3.26, P = 0.035), 60 (11.19 ± 1.35 vs 15.85 ± 1.58, P = 0.02), 90 (11.37 ± 1.42 vs 22.99 ± 4.12, P = 0.028) and 180 (13.63 ± 2.21 vs 21.93 ± 3.88, P = 0.008) d post-transplantation as opposed to CD4⁺CD69⁺IL-10⁺ and CD8⁺CD69⁺IL-10⁺ T cells which percentages were higher at 30 (25.21 ± 2.74 vs 8.54 ± 1.64, P < 0.001 and 22.37 ± 1.35 vs 17.18 ± 3.54, P = 0.032; respectively), 90 (16.85 ± 1.60 vs 4.07 ± 0.63, P < 0.001 and 23.06 ± 2.89 vs 10.19 ± 1.98, P = 0.002) and 180 (21.81 ± 1.72 vs 6.07 ± 0.98, P < 0.001 and 19.68 ± 2.27 vs 10.59 ± 3.17, P = 0.016) d post-transplantation. The auROC curve model determined the most accurate cut-off values to stratify LTr and KTr at high risk of OI and Cox Regression model confirmed these biomarkers as the most significant risk factors to opportunistic infection.

CONCLUSION

Post-transplant percentages of T-cell subsets differed significantly amongst infected- and non-infected-LTr and -KTr and yet this imbalance was found to contribute towards a worst clinical outcome.

Carcinoma of the Tongue in Renal Transplant Recipients: An Unusual Spectrum of De novo Malignancy at a Tertiary Care Center in India Over a Period of 26 Years

Renal transplant recipients are at a higher risk of malignancy. We report our experience and the critical differences in the presentation of malignancy in kidney transplant patients performed at our tertiary care center and followed up over the period of 1990–2015. A total of 338 live donor transplants performed in 332 patients were analyzed. Induction immunosuppression was used in 22 cases with interleukin-2 (IL-2) receptor antibody. Overall 299 patients were continued on calcineurin inhibitor (CNI)-based triple drug immunosuppression, 33 were off CNI with 13 of them receiving sirolimus additionally. A total of 16 malignancies including post transplant lymphoproliferative disease (5), oral cancer (5), lung cancer (2), hepatobiliary cancer (2), colon cancer (1), and skin cancer (1) were diagnosed in 15 patients. Over the 26-year follow up, 138 patients died of whom 12 died due to cancer. Cancer occurred in 4.7% of patients but accounted for 9.4% of deaths. Oral cancer occurred after a significantly longer latency of over 10 years (212 vs. 94 months, P = 0.00652). Despite the longer latency, oral cancer patients were younger at diagnosis (44.0 vs. 52 years, P = 0.01016) and had better outcome (Fisher's exact test, P = 0.0275). This was despite a longer overall follow-up for the oral cancer patients, reflecting the better outcome for these patients (24 vs. 4 months, P = 0.0278). This might be the result of relatively early diagnosis of oral cancers.

Risk Factors for Urinary Tract Infections in Renal Allograft Recipients: Experience of a Tertiary Care Center in Hyderabad, South India

Renal transplantation is an effective and commonly performed procedure for end-stage renal disease. Urinary tract infections are a major cause of morbidity and mortality in renal transplant patients. As data on postrenal transplant urinary tract infections from the Indian subcontinent are limited, the present study was conducted to estimate the burden of urinary tract infections in this vulnerable group of patients. This was a prospective study on patients undergoing renal transplantation in 2014 at our tertiary hospital in South India with a follow-up of 2 years to evaluate the risk factors for urinary tract infections. The prevalence of urinary tract infections was 41.9% with a male preponderance of 76.9%. Mean age of the 31 patients was 32.4 ± 10.2 years (range: 16-55 years). Gram-negative bacilli were the most common isolates with Escherichia coli being the predominant pathogen (53.3%). All the infections occurred within 1 year of transplantation with delayed graft function (P < 0.001; confidence interval [CI]: 29.0-96.3) and prolonged hospital stay (P = 0.0281; CI: 42.1-99.6) being the significant risk factors for acquiring urinary tract infections. Carbapenemase production was noted in 33.3% of isolates and all the Gram-negative organisms isolated in the 1st month of transplantation were carbapenem-resistant (CR) E. coli. The high rate of carbapenem-resistant organisms in the early posttransplant period is a point of concern, especially with cadaver transplants. Infection control practices and catheter care need to be strictly monitored to minimize the risk for UTI in the immediate posttransplant period.

Simultaneous Occurrence of Varicella Zoster Virus-Induced Pancreatitis and Hepatitis in a Renal Transplant Recipient: A Case Report and Review of Literature

INTRODUCTION

Gastrointestinal complications are common after renal transplantation, including oral lesions, esophagitis, gastritis, diarrhea, and colon carcinoma. The differential diagnosis is difficult in this scenario because multiple factors such as drugs, infections, and preexisting gastrointestinal disease come into play.

CASE PRESENTATION

We report a case of varicella zoster virus-induced pancreatitis and hepatitis in a renal transplant recipient. The patient underwent renal transplantation 3 years earlier and now presented with severe pain in the epigastrium radiating to his back and had raised serum lipase levels and skin lesions characteristic of varicella. Liver enzyme levels were also elevated. He was started on a regimen of acyclovir. His pain improved in 24 hours, and liver enzyme levels returned to normal in 48 hours.

DISCUSSION

There is a paucity of literature on the simultaneous occurrence of varicella zoster virus-induced hepatitis and pancreatitis in both immunocompetent and immunocompromised patients. Our case highlights the gastrointestinal complications of varicella infection in immunocompromised patients that may precede the characteristic dermatologic manifestations, and the fact that rarely both hepatitis and pancreatitis may be seen.

Cytomegalovirus seroprevalence in organ donors and kidney transplant recipients, Colombia, 2010-2014

INTRODUCTION

Cytomegalovirus infections have gained high importance for individuals that have received organ transplants given the clinical implications this may have in immunocompromised patients. 

OBJECTIVE

To describe the seroprevalence of cytomegalovirus in organ donors and recipients of kidney transplants nationwide from the six regions established by the Red Nacional de Donación y Trasplante. 

MATERIALS AND METHODS

We conducted a descriptive retrospective study that included 1,813 organ donors and 3,313 recipients of kidney transplants, and we calculated IgM and IgG seroprevalence for cytomegalovirus. IgG prevalence was stratified according to sex, age group, and region, and the results were analyzed in each donor-recipient pair and classified according to the risk. Statistical packages IBM SPSS®, Statistics 22, and Epi Info 7 were utilized. 

RESULTS

IgG prevalence for cytomegalivirus was 86.8% in donors and 91.0% in kidney transplant recipients with statistical significance observed for age, geographical location, and between donors and recipients. We analyzed 1,764 pairs of donors and recipients, of which 91.4% were categorized as having intermediate risk. 

CONCLUSIONS

The results of this study showed high cytomegalovirus infection rates in Colombia. Given the risk, categorization of patients undergoing transplants, measures should be adopted by medical teams to minimize risks.

In Kidney Transplant Recipients With a Positive Virtual Crossmatch, High PRA was Associated With Lower Incidence of Viral Infections

BACKGROUND

There is little information on the incidence, risk factors, and outcomes associated with CMV and BK infections in sensitized patients.

METHODS

We examined 254 consecutive kidney transplant recipients with positive virtual crossmatch and negative flow crossmatch.

RESULTS

A total of 111 patients (43%) developed CMV disease or BK infection or nephropathy (BKVN). Specifically, 78 patients (30.7%) developed BK infection, 19 (7.5%) had BKVN, and 33 (12.9%) presented with CMV disease. Four patients (1.5%) developed both infections. Mean time from transplant to diagnosis for BK and CMV was 4.07 ± 3.10 and 8.35 ± 5.20 months, respectively. African American (HR, 2.64; 95% CI, 1.37-5.07; P = 0.003), thymoglobulin induction (HR, 2.18; 95% CI, 1.38-3.43; P = 0.0008), DSA greater than 500 MFI at transplant (HR, 1.64; 95% CI, 1.05-2.57; P = 0.03), history of diabetes (HR, 1.62; 95% CI, 1.01-2.60; P = 0.04), CMV D+/R- (HR, 2.30; 95% CI, 1.06-5.01; P = 0.03), and acute rejection (HR, 1.49; 95% CI, 0.99-2.24; P = 0.05) were associated with increase incident of BK/CMV, whereas rituximab (HR, 0.47; 95% CI, 0.24-0.91; P = 0.02), peak PRA greater than 80% (HR, 0.48; 95% CI, 0.27-0.84; P = 0.01), and living donor transplant (HR, 0.57; 95% CI, 0.36-0.87; P = 0.01) were associated with a lower likelihood of infection. Thymoglobulin induction (HR, 2.50; 95% CI, 1.02-6.13; P = 0.04), and peak PRA greater than 80% (HR, 0.45; 95% CI, 0.23-0.86; P = 0.02) remained significant predictors of infection after multivariate adjustment.

CONCLUSIONS

Although more than 40% of patients with a positive virtual crossmatch presented with BK infection/CMV disease, high PRA greater than 80% seemed to be protective.

Total joint arthroplasty in transplant recipients: in-hospital adverse outcomes

This study aims to determine in-hospital complications and mortality in transplant recipients following total joint arthroplasty. The Nationwide Inpatient Sample database was queried for patients with history of transplant and joint arthroplasty (primary or revision) from 1993 to 2011. Kidney transplant increased risk of surgical site infection (SSI) and wound infections (OR=2.03), systemic infection (OR=2.85), deep venous thrombosis (OR=2.07), acute renal failure (ARF) (OR=3.48), respiratory (OR=1.34), and cardiac (OR=1.21) complications. Liver transplant was associated with SSI/wound infections (OR=2.32), respiratory complications (OR=1.68), cardiac complications (OR=1.34), and ARF (OR=4.48). Other transplants grouped together were associated with wound complications (OR=2.13), respiratory complications (OR=2.06), and ARF (OR=4.42). Our study suggests these patients may be at increased risk of in-hospital complications, particularly ARF in renal and liver transplant patients.

Prevalence and dynamics of cytomegalovirus infection among patients undergoing chronic hemodialysis

Cytomegalovirus (CMV) is an important pathogen in immunocompromised individuals. The aim of this study was to analyze prevalence and dynamics of CMV infection among patients undergoing chronic hemodialysis. From 2010 to 2012, a total of 162 patients and 160 control subjects were tested for the presence of CMV IgM and IgG antibodies using enzyme-linked immunosorbent assay. IgM/IgG reactive samples were further evaluated for IgG avidity to confirm or rule out recent primary CMV infection. The overall IgG seropositivity was higher in hemodialysis patients compared to controls (90.7% vs. 81.9%; crude odds ratio [OR] =2.02, 95% confidence interval [CI] =1.05–3.89; OR adjusted for age and gender = 2.18, 95% CI = 1.05–4.55). CMV IgG antibody titers were similar in both groups. There was no difference in CMV prevalence between males (87.9%) and females (96.3%). According to age, a progressive increase in seropositivity was observed in both hemodialysis patients and the control group. Three hemodialysis patients (1.9%) developed recurrent CMV infection (positive IgM with high avidity IgG antibodies). In one patient (2.9%), seroconversion was documented during the second year of the follow-up period indicating primary infection. In contrast, in the control group, recent primary CMV infection (positive IgM with low/borderline IgG avidity) was demonstrated in three subjects (1.9%), whereas one (0.6%) developed recurrent infection. On multivariate logistic regression, hemodialysis and older age were significant predictors for CMV seropositivity.

Successful three-way kidney paired donation transplantation: The first Indian report

Providing transplantation opportunities for patients with incompatible live donors through kidney paired donation (KPD) is an important strategy for easing the crisis in organ availability. KPD is can overcome the barriers when the only living potential donors are deemed unsuitable owing to an incompatibility of blood type, of human leukocyte antigen cross-match, or both. In KPD, the incompatibility problems with two donor recipient pairs can be solved by exchanging donors. In the absence of well-organized deceased donor program, or transplantation with desensitization protocol and ABO incompatible transplantation, living donor KPD promises hope to the growing number of patients suffering from end-stage renal disease in India. We report our first successful three-way KPD transplantation from India. In an era of organ shortage, this approach is relevant to encourage wider participation from KPD donors and transplant centers to prevent commercial transplantation.

Outcome of live and deceased donor renal transplantation in patients aged ≥55 years: A single-center experience

Renal transplantation (RTx) has now become an accepted therapeutic modality of choice for elderly ESRD patients. This single-center study was undertaken to evaluate the outcome of RTx in ESRD patients ≥55 years. A total of 103 patients underwent RTx 79 living related living donors [LD], 24 deceased donors [DD]) at our center. Post-transplant immunosuppression consisted of calcineurin inhibitor-based regimen. The mean donor age was 58.3 years in the LD group and 59.5 years in the DD group. Male recipients constituted 92% in LD and 75% in DD group. In living donor renal transplantation, 1- and 5-year patient survival was 93% and 83.3% respectively and death-censored graft survival was 97.3% and 92.5% respectively. There were 12.6% biopsy proven acute rejection (BPAR) episodes and 12.6% patients were lost, mainly due to infections. In deceased donor renal transplantation, 1- and 5-year patient survival was 79.1% and 74.5% respectively and death-censored graft survival was 95.8% and 85.1% respectively. There were 12.5% BPAR episodes and 25% of patients were lost, mainly due to infections. RTx in ESRD (≥55 years) patients has acceptable patient and graft survival if found to have cardiac fitness and therefore should be encouraged.

Bronchiolitis obliterans organizing pneumonia (BOOP) after renal transplantation

A 42-year-old renal transplant recipient was admitted with fever, anorexia, malaise, nonproductive cough, and dyspnea of 1-week duration. Multiple cultures of blood, sputum, and urine were negative. The possibility of bronchiolitis obliterans with organizing pneumonia (BOOP) was considered when pulmonary infiltrate did not respond to conventional antibiotic therapy. High-resolution computed tomography of the chest revealed patchy air-space consolidation and ground-glass opacities, predominantly located in the periphery of the lungs. Cultures and stains of bronchoalveolar lavage specimen and bronchoscopic biopsy of lung tissue were negative for organisms such as Pneumocystis (carinii) jiroveci, bacteria, Mycobacterium tuberculosis, cytomegalovirus, fungi, and atypical germs, and showed evidence of BOOP. The patient recovered completely after treatment with steroids.

Outcome of kidney paired donation transplantation to increase donor pool and to prevent commercial transplantation: a single-center experience from a developing country

BACKGROUND

Economic constraints in operating an effective maintenance dialysis program leaves renal transplantation as the only viable option for end-stage renal disease patients in India. Kidney paired donation (KPD) is a rapidly growing modality for facilitating living donor (LD) transplantation for patients who are incompatible with their healthy, willing LD.

MATERIALS AND METHODS

The aim of our study was to report a single-center feasibilities and outcomes of KPD transplantation between 2000 and 2012. We performed KPD transplants in 70 recipients to avoid blood group incompatibility (n = 56) or to avoid a positive crossmatch (n = 14).

RESULTS

Over a mean follow-up of 2.72 ± 2.96 years, one-, five- and ten-year patient survival were 94.6, 81, 81 %, and death-censored graft survival was 96.4, 90.2, 90.2 %, respectively. Ten percent of patients were lost, mainly due to infections (n = 4). There was 14.2 % biopsy-proven acute rejection, and 5.7 % interstitial fibrosis with tubular atrophy eventually leading to graft loss.

CONCLUSION

The incidences of acute rejection, patient/graft survival rates were acceptable in our KPD program and, therefore, we believe it should be encouraged. These findings are valuable for encouraging participation of KPD pairs and transplant centers in national KPD program. It should be promoted in centers with low-deceased donor transplantation. Our study findings are relevant in the context of Indian government amending the Transplantation of Human Organs Act to encourage national KPD program. To our knowledge, it is largest single-center report from India.

Outcome of renal transplantation from deceased donors after cardiac death: a single-center experience from a developing country

BACKGROUND

Limited information is available in the literature about the use of organs from donation after cardiac death (DCD) renal transplantation (RTx) from a developing country.

MATERIAL AND METHODS

We report RTx outcome between DCD donors ≥70 years (Group 1; n = 14; mean age, 75.7 ± 5.81) and DCD donors <70 years (Group 2; n = l9; mean age, 51.7 ± 10.1) between January 1999 and January 2012. The mean age of recipients was 39.5 ± 14.7 years, 24 of whom were males. The mean donor age was 61.9 ± 14.6 years, 21 of whom were males. All recipients received single-dose thymoglobulin induction followed by immunosuppression with a steroid, a calcineurin inhibitor, and mycophenolate mofetil or azathioprine. Statistical analysis used chi-square test and unpaired Student t test. Kaplan-Meier curves were used for survival analysis.

RESULTS

Over a mean follow-up of 3.21 ± 3.46 years, one-, five-, and ten-year, patient survival rates were 77%, 67.4%, and 67.4%, respectively, and death-censored graft survival rates were 85.7% for one, five, and ten years. Delayed graft function (DGF) was observed in 36.4% (n = 12) with 12.1% (n = 4) biopsy-proven acute rejection (BPAR). Patient survival (P = .27), graft survival (P = .20), DGF (P = .51), and BPAR (P = .74) were similar in 2 groups. A total of 27.2% (n = 9) of patients died, mainly due to infections (n = 5).

CONCLUSION

Given the widespread organ shortage, outcomes of controlled DCD renal transplantation has a potential to expand the donor pool and shorten the waiting list for RTx, encouraging the use of this approach even in low-income countries.

BK virus excretion in acquired immunocompromised children: A comparison between kidney transplant recipients and steroid resistant nephrotic syndrome

BACKGROUND

BK virus (BKV) is ubiquitous in human beings. Virus reactivation may occur in immunocompromised settings. The aim of this study was to compare BKV excretion in acquired immunocompromised children (kidney transplant recipients and steroid resistant nephrotic syndrome) with normal population.

MATERIALS AND METHODS

One hundred and thirty one participants less than 20 years were recruited in the case-control study from June 2009 to December 2010. The participants consisted of 40 patients with steroid resistant nephrotic syndrome (subgroup 1), 39 kidney transplant recipients (subgroup 2) and 52 normal populations as control group. The first morning urine samples were analyzed in duplicate by conventional polymerase chain reaction (PCR) method for BKV.

RESULTS

Nine participants out of 131 had positive results for BKV. Three patients in subgroup 1 (7.5%), two patients in subgroup 2 (5.1%) and six people (11.5%) in the control group had positive PCR results for urinary BKV. No significant difference was noted among groups, P = 0.53. The mean of glomerolar filtration rates in participants with positive and negative results for BKV were 125.5 ± 30.8 ml/min/m(2) and 132.2 ± 42.5 ml/min/m(2) respectively, P = 0.8.

CONCLUSION

Acquired immunocompromised conditions did not increase the chance of urine BKV excretion in our study.

Stem cell transplantation in living donor renal transplantation for minimization of immunosuppression

BACKGROUND

We present our experience of living-donor renal transplantation (LDRT) using pretransplant stem cell transplantation (SCT) where we have successfully achieved minimization of immunosuppression.

METHODS

Nine hundred sixteen patients underwent LDRT between 2007 and 2011: 606 under tolerance induction protocol (TIP) and 310 with our usual triple immunosuppression of calcineurin inhibitors (CNI), mycofenolate sodium (MMF), and prednisone (controls). The test group (TIP) was stratified into group 1, 1 haplomatch or greater (n=392), group 3, less than 1 haplomatch (n=214); controls were similarly stratified to group 2, 1 haplomatch or greater (n=179) and group 4, less than 1 haplomatch (n=131). The TIP consisted of donor-specific transfusion, adipose tissue-derived mesenchymal and hematopoietic stem cell transplantation, and nonmyeloablative conditioning with total lymphoid irradiation, cyclophosphamide, and rabbit-antithymocyte globulin. Posttransplant IS consisted of prednisone, CNI, or MMF, all in low doses.

RESULTS

Four-year patient survival was 93.5%, 90.7%, 88.7%, and 82.7% in groups 1 through 4, respectively, and death-censored 4-year allograft survival was 94.8%, 95.4%, 94.5%, and 74.6%, respectively. Mean serum creatinine (mg/dL) for groups 1 through 4, respectively, at 4 years was 1.26, 1.57, 1.29, and 2.1. The number of rejection episodes was highest in group 4 and lowest in group 1. Minimization of IS was successfully achieved in 82.9% patients in group 1 and in 61.7% patients in group 3, whereas no minimization in groups 2 and 4. Stem cell transplantations were safe.

CONCLUSION

Stem cell transplantation is effective in IS minimization in LDRT resulting in good graft function and patient and graft survival at 4 years.

Long-term outcome of deceased donor renal transplantation in pediatric recipients: a single-center experience from a developing country

RTx is best treatment for children with ESRD. Data scarcity on DDRTx outcome in children prompted us to review our experience. This study was undertaken to evaluate patient/graft survival, function vis-a-vis SCr, rejection episodes, and mortality in DDRTx performed in 37 children between 1998 and 2011. The most common recipient diseases leading to ESRD were congenital anomalies of kidney and urinary tract (48.6%) and chronic glomerulonephritis (18.9%). Mean recipient age was 13.8 ± 3.1 yr; 67.5% (n = 25) were men. Mean donor age was 38.8 ± 18.6 yr; 48.5% (n = 18) were men. Mean dialysis duration pre-transplantation was 15.5 ± 3.5 months. All recipients received r-ATG, and triple immunosuppression. Over a mean follow-up of 3.93 ± 3.5 yr, patient and graft survival rates were 72.9% (n = 27) and 83.7% (n = 31), respectively, with a mean SCr of 1.1 mg/dL; 21.6% (n = 8) of patients had acute rejection episodes; 24.3% (n = 9) of patients had DGF. A total of 27% (n = 10) patients died, mainly owing to infections (n = 6) and cardiovascular disease (n = 3). DDRTx is a viable option for children and achieves acceptable graft function with patient/graft survival over long-term follow-up, encouraging use of this approach.

Spectrum of cytomegalovirus-induced renal pathology in renal allograft recipients

Viral infections in renal allograft recipients constitute an important cause of renal graft dysfunction. They have shown an increasing incidence coinciding with more potent immunosuppression regimens. Cytomegalovirus (CMV) is well-known cause of a tubulointerstitial nephritis rich in plasma cells with cytopathic changes in tubular epithelial and endothelial cells. However, involvement of glomeruli and larger arteries in the absence of tubulointerstitial disease is rare. In this study, we demonstrated the spectrum of renal disease caused by CMV among renal allograft recipients. Retrospective analysis of 2900 renal allograft biopsies performed over a 10-year period revealed 10 cases of CMV infection, with half of them (5/10) detected in 2010-2011. Although tubulointerstitial nephritis due to CMV was the most common lesion (7/10), we noted an increased incidence of CMV glomerulopathy with (1/10) or without (3/10) coexisting tubulointerstitial CMV disease. Isolated glomerular involvement was characterized by a relative lack of inflammation in any of the compartments along with the presence of cytopathic changes in the glomerular endothelial cells and podocytes. Another patient had CMV-induced thrombotic microangiopathy. The coexistent diseases were calcineurin inhibitor toxicity (n = 1), antibody-mediated rejection (n = 1), cellular rejection (n = 2), and invasive fungal infection (n = 1). In conclusion, there is a wide spectrum of CMV-induced lesions. CMV glomerulopathy is characterized by cytopathic changes in glomerular endothelial cells and podocytes with a lack of significant inflammation. In contrast, CMV-induced arteriopathy can present as thrombotic microangiopathy. Coinfection with other pathogens like invasive fungi can lead to graft failure.

Successful treatment of Bronchiolitis obliterans with organizing pneumonia in dialysis patient

A 42-year-old end stage renal disease (ESRD) patient was admitted with fever, anorexia, malaise, non-productive cough, and dyspnea, of one-week duration. Multiple cultures of the blood, sputum, and urine were negative for microorganisms. The possibility of bronchiolitis obliterans with organizing pneumonia (BOOP) was considered when patient with pulmonary infiltrate did not respond to conventional antibiotic therapy and frequent hemodyalisis. High-resolution computed tomography of the chest revealed patchy air-space consolidation, ground-glass opacities, and small nodular opacities, predominantly located at the peripheral part of the lungs. Cultures and stains of bronchoalveolar lavage (BAL) specimen and bronchoscopic biopsy of lung tissue were negative for organisms [bacteria, mycobacterium tuberculosis, PCP, fungus, and atypical organism] and showed evidence of BOOP. Patient recovered completely with early diagnosis and treatment with steroids and underwent successful renal transplantation with wife as donor without postoperative complication and relapse.

Outcome of deceased donor renal transplantation in diabetic nephropathy: a single-center experience from a developing country

BACKGROUND

Type 2 diabetes mellitus (DM) is the commonest cause of end-stage renal disease (ESRD) worldwide. Renal transplantation (RTx) is the best therapeutic modality for such patients. First-degree relatives of patients with type 2 DM have high risk of diabetes/pre-diabetes. Parents are often too old to be suitable donors, and siblings/children/spouse are either not suitable/acceptable or do not come forward for organ donation. This leaves deceased donation (DD) as only suitable donors. Data scarcity on DDRTx outcome in diabetic nephropathy (DN) prompted us to review our experience. This retrospective single-center 10-year study was undertaken to evaluate patient/graft survival, graft function, rejection episodes, and mortality in these patients.

MATERIALS AND METHODS

Between January 2001 and March 2011, thirty-five DN-ESRD patients underwent DDRTx in our center following cardiac fitness assessment of recipients. All patients received single-dose rabbit-anti-thymocyte globulin for induction and steroids, calcineurin inhibitor, and mycophenolate mofetil/azathioprine for maintenance immunosuppression. Mean recipient age was 49.66 ± 6.76 years, and 25 were men. Mean donor age was 50 ± 16.45 years, 23 were men.

RESULTS

Over a mean follow-up of 2.28 ± 2.59 years, patient and graft survival rates were 68.5% and 88.5%, respectively, with mean SCr of 1.9 ± 0.62 mg/dl. Delayed graft function was observed in 34.3% patients, and 25.7% had biopsy-proven acute rejection; 31.5% patients died, mainly because of infections (22.8%), coronary artery disease (2.86%), and cerebrovascular events (5.7%).

CONCLUSION

DDRTx in patients with DN has acceptable graft function and patient/graft survival over 10-year follow-up in our center and, therefore, we believe it should be encouraged.

Protective effect of probiotics on intestinal barrier function in malnourished rats after liver transplantation

BACKGROUND

Most patients waiting for liver transplantation have end-stage liver diseases with malnutrition, which is prone to induce intestinal barrier dysfunction after liver transplantation. We aimed to study the effect of probiotics on intestinal barrier function in malnourished rats following liver transplantation with long-term antibiotics.

METHODS

Twelve Lewis rats were selected as donors. Twelve BN rats, which served as recipients, were subjected to malnutrition by semi-starvation for 4-5 weeks. They were randomly divided into two groups: a control group which received phosphate-buffered saline and a probiotics group which received Bifidobacterium and Lactobacillus. All recipients were injected with intramuscular imipenem and subcutaneous cyclosporine A. Furthermore, six normal BN rats without any drugs or operations served as a normal group. Eight days after operation, all rats were sacrificed for examination of the following parameters: serum levels of endotoxin and TNF-alpha, bacterial translocation, intestinal microflora, ileocecal sIgA, lymphocyte numbers, and phenotypes (CD4, CD8, alphabetaTCR, gammadeltaTCR) of Peyer's patches.

RESULTS

In recipients subjected to malnutrition, weight decreased by 20% and they survived until 8 days after operation. Compared with the normal group, all recipients on postoperative day 8 showed increased levels of serum endotoxin and TNF-alpha as well as increased counts of translocated bacteria. Meanwhile, there were decreases in counts of Bifidobacterium and Lactobacillus in the ileocecum, sIgA concentration, and lymphocytes of Peyer's patches. Moreover, partial alteration in lymphocyte phenotypes was evidenced by elevated ratios of CD8+ and gammadeltaTCR+ lymphocytes. In contrast, compared to the control group, supplementation with probiotics reduced the levels of serum endotoxin, TNF-alpha and bacterial translocation, increased the counts of Bifidobacterium and Lactobacillus, the concentration of sIgA and lymphocytes of Peyer's patches, and also slightly restored the alteration of lymphocyte phenotypes.

CONCLUSION

Supplementation with probiotics including Bifidobac-terium and Lactobacillus promoted partial restoration of intestinal microflora and improved intestinal barrier function in malnourished rats after liver transplantation with long-term use of antibiotics.

Unusual infections: Femoral abscess due to Nocardia abscessus in a patient suffering from metastatic peripheral bronchial carcinoma and hygienic consequences

During the course of a peripheral bronchial carcinoma with pulmonary and cerebral metastases a femoral abscess developed in a 49 year-old patient after radio- and chemotherapy. A bacterial strain, which was isolated four times from a deep wound of the left thigh was tentatively identified as a member of the genus Nocardia on the basis of selected phenotypic and chemotaxonomic characteristics. The isolate was confirmed to belong to Nocardia abscessus by 16S rRNA gene sequencing. This species had previously been described as the causative agent of soft tissue infections. Although rare, nocardia soft tissue infections as complication of systemic nocardiosis are typical air born infections of immuncompromised patients and need specific attention. Infection prevention can be realized by restriction of soil and aerosol (builder's dust) together with antibiotic intervention (oral administration of trimethoprim/sulfamethoxazole).