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Yahav D, Gitman MR, Margalit I, Avni T, Leeflang MMG, Husain S. Screening for Latent Tuberculosis Infection in Solid Organ Transplant Recipients to Predict Active Disease: A Systematic Review and Meta-Analysis of Diagnostic Studies. Open Forum Infect Dis 2023; 10:ofad324. [PMID: 37559757 PMCID: PMC10407303 DOI: 10.1093/ofid/ofad324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/26/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND This is a systematic review and meta-analysis of diagnostic test accuracy studies to assess the predictive value of both tuberculin skin test (TST) and interferon-gamma release assays (IGRA) for active tuberculosis (TB) among solid organ transplantation (SOT) recipients. METHODS Medline, Embase, and the CENTRAL databases were searched from 1946 until June 30, 2022. Two independent assessors extracted data from studies. Sensitivity analyses were performed to investigate the effect of studies with high or low risk of bias. Methodological quality of each publication was assessed using QUADAS-2. RESULTS A total of 43 studies (36 403 patients) with patients who were screened for latent TB infection (LTBI) and who underwent SOT were included: 18 were comparative and 25 noncomparative (19 TST, 6 QuantiFERON-TB Gold In-Tube [QFT-GIT]). For IGRA tests taken together, positive predictive value (PPV) and negative predictive value (NPV) were 1.2% and 99.6%, respectively. For TST, PPV was 2.13% and NPV was 95.5%. Overall, PPV is higher when TB burden is higher, regardless of test type, although still low in absolute terms. Incidence of active TB was similar between studies using LTBI prophylaxis (mean incidence 1.22%; 95% confidence interval [CI], .2179-2.221) and those not using prophylaxis (mean incidence 1.045%; 95% CI, 0.2731-1.817; P = .7717). Strengths of this study include the large number of studies available from multiple different countries; limitations include absence of gold standard for diagnosis of latent TB and low incidence of active TB. CONCLUSIONS We found both TST and IGRA had a low PPV and high NPV for the development of active TB posttransplant. Further studies are needed to better understand how to prevent active TB in the SOT population.
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Affiliation(s)
- Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Melissa R Gitman
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ili Margalit
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tomer Avni
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Medicine A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Mariska M G Leeflang
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Shahid Husain
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada
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Kwon DE, Han SH, Han KD, La Y, Lee KH. Incidence rate of active tuberculosis in solid organ transplant recipients: Data from a nationwide population cohort in a high-endemic country. Transpl Infect Dis 2021; 23:e13729. [PMID: 34505751 DOI: 10.1111/tid.13729] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND The management of active tuberculosis (TB) in solid organ transplantation (SOT) recipients is challenging given the pharmacological interaction and the potential delays in diagnosis due to atypical presentation. The incidence rates (IRs) of post-SOT TB from the whole recipients' cohort in a high-endemic country have not been evaluated. METHODS We established a SOT cohort (n = 15 598) and confirmed cases of TB between 2011 and 2015 from the Korean National Health Insurance Database using ICD-10 codes. After excluding 1302 and 180 SOT-recipients due to age (<18 years) and presence of pre-SOT TB and/or treatment for latent TB during wash-out period between 2006 and cohort entry, we analyzed 14 116 SOT recipients and 70 580 individuals with no history of SOT matched by age and sex. The hazard ratios (HRs) of IRs were adjusted for age, sex, low-income status, diabetes mellitus, chronic co-morbidities, and anti-TNF-α therapy. RESULTS The IR of TB was significantly higher (adjusted HR [aHR]: 6.1, 95% confidence interval [CI]: 4.5-7.6) in SOT recipients (4.9/1000 person-years) than in non-SOT individuals (0.8/1000 person-years). Of the transplanted organs, the pancreas (pancreas alone and simultaneous pancreas-kidney) and lung had the highest IR (aHR: 16.3 [6.1-42.2] and 16.1 [5.9-43.8], respectively). The use of anti-thymocyte globulin and azathioprine was associated with a higher IR (aHR: 1.53 [1.01-2.43] and 3.92 [1.21-12.47], respectively), but basiliximab was associated with a lower IR (aHR: 0.67 [0.48-0.98]). CONCLUSION The IR of TB in SOT recipients, especially in the pancreas and lung, was significantly higher than that in the non-SOT population.
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Affiliation(s)
- Da Eun Kwon
- Department of Internal Medicine, Division of Infectious Disease, Yonsei University College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Sang Hoon Han
- Department of Internal Medicine, Division of Infectious Disease, Yonsei University College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Kyung Do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Yeonju La
- Department of Internal Medicine, Division of Infectious Disease, Yonsei University College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Kyoung Hwa Lee
- Department of Internal Medicine, Division of Infectious Disease, Yonsei University College of Medicine, Yonsei University, Seoul, Republic of Korea
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Nasir N, Sarfaraz S, Khanum I, Ansari T, Nasim A, Dodani SK, Luxmi S. Tuberculosis in Solid Organ Transplantation: Insights from TB Endemic Areas. Curr Infect Dis Rep 2021. [DOI: 10.1007/s11908-021-00756-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ramírez-Sánchez IC, García K, Nieto-Ríos JF. Multifocal skeletal tuberculosis with mycobacteremia after kidney transplantation: A case report. Transpl Infect Dis 2021; 23:e13591. [PMID: 33655691 DOI: 10.1111/tid.13591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 02/05/2021] [Accepted: 02/14/2021] [Indexed: 01/29/2023]
Abstract
Solid organ transplant recipients have a higher risk of active Mycobacterium tuberculosis infection (TB) compared to the general population. Recognized risk factors are immunosuppressant use, graft dysfunction, diabetes mellitus, liver disease caused by the hepatitis C virus, and co-infections by other opportunists. Most of the active TB cases reported in solid organ transplant recipients occur in kidney transplant patients, especially if they come from M tuberculosis-endemic areas. Extrapulmonary and disseminated TB are among the wide spectrum of clinical presentations found, but the lungs are the most common organ affected. Disseminated disease occurs in up to a third of the affected population, however, multifocal osteoarticular TB with mycobacteremia is unusual. We report the case of a kidney transplant patient with disseminated M tuberculosis infection, who presented with multifocal skeletal TB.
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Affiliation(s)
- Isabel Cristina Ramírez-Sánchez
- Infectious Diseases Section, Internal Medicine Department, Hospital Pablo Tobón Uribe, Medical School, Medellín, Colombia.,Infectious Diseases Section, Internal Medicine, Universidad de Antioquia Medical School, Medellín, Colombia
| | - Karen García
- Internal Medicine Department, Universidad de Antioquia Medical School, Medellín, Colombia
| | - John Fredy Nieto-Ríos
- Internal Medicine Department, Universidad de Antioquia Medical School, Medellín, Colombia.,Nephrology Section, Internal Medicine Department, Hospital Pablo Tobón Uribe, Medical School, Medellín, Colombia
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Abstract
Solid organ transplant recipients are at an increased risk of tuberculosis and transplant candidates should be screened early in their evaluation with a detailed history, tuberculin skin test or tuberculosis interferon-gamma release assay, and chest radiograph. For latent tuberculosis treatment, isoniazid and rifamycin-based regimens have advantages and disadvantages; treatment decisions should be customized. Tuberculosis after solid organ transplantation generally occurs after months or years; early infections should raise the possibility of donor-derived infections. Tuberculosis diagnosis and treatment in solid organ transplant recipients may be complicated by protean manifestations, drug interactions, and adverse drug reactions.
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Abad CLR, Razonable RR. Mycobacterium tuberculosis after solid organ transplantation: A review of more than 2000 cases. Clin Transplant 2018; 32:e13259. [PMID: 29656530 DOI: 10.1111/ctr.13259] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Mycobacterium tuberculosis (TB) is a common pathogen worldwide, and it may cause significant infection after solid organ transplantation (SOT). We reviewed all reported TB cases to provide an update on its epidemiology, clinical presentation, management, and outcome after SOT. METHODS MEDLINE, EMBASE, and OVID were reviewed from January 1, 1998, to December 31, 2016, using keywords tuberculosis and solid organ transplant or transplantation. RESULTS There were 187 publications reporting 2082 cases of TB among kidney (n = 1719), liver (n = 253), heart (n = 77), lung (n = 25), and kidney-pancreas (n = 8) recipients. Among cohort studies, the median incidence was 2.37% (range, 0.05%-13.27%) overall. Most TB disease was considered reactivation of latent infection, occurring beyond the first year after SOT. Early-onset cases were seen among donor-derived TB cases. Fever was the most common symptom. Radiologic findings were highly variable. Extrapulmonary and disseminated TB occurred 29.84% and 15.96%, respectively. Multidrug-resistant TB was rare. Treatment using 4 or 5 drugs was commonly associated with hepatotoxicity and graft dysfunction. All-cause mortality was 18.84%. CONCLUSIONS This large review highlights the complexity of TB after SOT. Reactivation TB, donor-transmitted infection, extrapulmonary involvement, and disseminated disease are common occurrences. Treatment of TB is commonly associated with hepatotoxicity and graft dysfunction.
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Affiliation(s)
- Cybele Lara R Abad
- Section of Infectious Diseases, Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Raymund R Razonable
- Division of Infectious Diseases, Department of Medicine, The William J Von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine and Sciences, Rochester, MN, USA
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Jambaldorj E, Han M, Jeong JC, Koo TY, Min SI, Song EY, Ha J, Ahn C, Yang J. Poor predictability of QuantiFERON-TB assay in recipients and donors for tuberculosis development after kidney transplantation in an intermediate-TB-burden country. BMC Nephrol 2017; 18:88. [PMID: 28292277 PMCID: PMC5351170 DOI: 10.1186/s12882-017-0506-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 03/09/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) is a common opportunistic infection after kidney transplantation (KT). The QuantiFERON-TB-Gold In-Tube test (QFT) is widely used for assessing latent TB; however, it is currently unclear whether the pre-KT QFT of the recipient and donor can predict post-KT TB. METHODS We retrospectively reviewed patients who received KT between January 2009 and December 2015 at Seoul National University Hospital. The QFT was performed in 458 KT recipients and 239 paired living donors, and 138 KT recipients underwent both the QFT and tuberculin skin test (TST). After excluding 12 patients diagnosed as having clinically latent TB, we evaluated whether the QFT of the recipient and donor was predictive for new-onset active TB after KT. RESULTS The QFT was positive in 101 (22.1%) recipients and associated with clinically latent TB before KT (P < 0.05). However, agreement between the TST and QFT was poor (κ = 0.327). Post-KT TB occurred in 1 of 95 recipients with a positive QFT, and 2 cases of TB occurred among 351 patients with a negative or indeterminate QFT. The incidence of TB was 242 cases/100,000 person-years among 446 KT recipients with a median follow-up of 30.2 months. The QFT of recipients could not predict post-KT TB in Poisson regression analysis (relative risk [RR], 1.847; 95% confidence interval [CI], 0.168-20.373; P = 0.616). Of 234 living donor-recipient pairs, the QFT of the recipient (RR, 5.012; 95% CI, 0.301-83.430; P = 0.261) and QFT of the donor (RR, 1.758; 95% CI, 0.106-29.274; P = 0.694) could not predict post-KT TB. CONCLUSION The QFT of recipients or living donors pre-KT cannot predict the short-term development of post-KT TB in an intermediate TB-burden country.
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Affiliation(s)
- Enkthuya Jambaldorj
- Transplantation Research Institute, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Miyeun Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Cheol Jeong
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Tai Yeon Koo
- Transplantation Center, Seoul National University Hospital, Seoul, Korea
| | - Sang Il Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Young Song
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jongwon Ha
- Transplantation Research Institute, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.,Transplantation Center, Seoul National University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Curie Ahn
- Transplantation Research Institute, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Transplantation Center, Seoul National University Hospital, Seoul, Korea
| | - Jaeseok Yang
- Transplantation Research Institute, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea. .,Transplantation Center, Seoul National University Hospital, Seoul, Korea. .,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.
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Agarwal SK, Bhowmik D, Mahajan S, Bagchi S. Impact of type of calcineurin inhibitor on post-transplant tuberculosis: Single-center study from India. Transpl Infect Dis 2016; 19. [DOI: 10.1111/tid.12626] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 07/24/2016] [Indexed: 02/04/2023]
Affiliation(s)
- Sanjay K. Agarwal
- Department of Nephrology; All India Institute of Medical Sciences; New Delhi India
| | - Dipankar Bhowmik
- Department of Nephrology; All India Institute of Medical Sciences; New Delhi India
| | - Sandeep Mahajan
- Department of Nephrology; All India Institute of Medical Sciences; New Delhi India
| | - Soumita Bagchi
- Department of Nephrology; All India Institute of Medical Sciences; New Delhi India
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