Post-renal transplant cytomegalovirus infection: study of risk factors

OBJECTIVES

Cytomegalovirus (CMV) is a common opportunistic infection following renal transplantation (RTx). It responds promptly to antiviral treatment. The mortality rate reaches 90% if untreated. Identification of risk factors helps in the early diagnosis of CMV. We studied demographic features, risk factors, and outcomes associated with CMV infection in RTx recipients despite ganciclovir prophylaxis.

MATERIALS AND METHODS

We reviewed 720 RTx recipients between 2007 and 2009. We examined the serostatus of the donor and recipient before transplantation using an enzyme-linked immunosorbent assay, and diagnosed CMV infections in recipients by CMV DNA detection with a polymerase chain reaction.

RESULTS

A total of 42 of 750 (5.6%) patients were identified to display CMV infection (69.1%) or disease (30.9%). Their mean age was 34 ± 13.5 years, with 80.9% men. CMV serologic status was D+/R- in 21.4% and D+/R+ in 59.5% patients. Fever, malaise (76.2%), and leukopenia (52.3%) were the commonest presenting symptoms; diabetes (30.9%) and hepatitis C virus (28.6%) the commonest comorbid conditions. Risk factors were triple drug immunosuppression (47.6%), antithymocyte globulin ATG induction (54.8%), and a rejection episode (26.1%) and methylprednisolone (76.2%) which were more common in CMV disease than infection. Mean CMV DNA at diagnosis was 78,803; 71.2% patients developed CMV within 6 months posttransplantation, the majority occurring after 3 months. With a mean follow-up of 4 ± 1.9 years, patient and graft survival rates were 85.7% and 81% with a mean serum creatinine value of 1.83 ± 12 mg/dL.

CONCLUSIONS

Universal CMV prophylaxis was associated with a low incidence (5.6%) and mild form of CMV disease among our patients.

Mucormycosis in renal transplant recipients: predictors and outcome

Mucormycosis, though uncommon, is associated with high mortality in transplant recipients. This study was conducted to assess the incidence and risk factors associated with mucor infection and its outcome. We retrospectively reviewed the hospital records for evidence of mucor infection in patients transplanted between January 2005 and December 2009 at the Department of Nephrology and Clinical Transplantation (IKDRC), Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India. The patient demographics, symptoms, diagnostic techniques and outcomes were analyzed. Out of a total of 1,330 transplants, 16 patients (1.20%) had evidence of mucor infection, including 14 males and two females. The mean age of the patients was 43.8 years. The time interval between transplantation and disease onset varied greatly (range: 1 month to 7 years; median 13.8 months). The presenting symptoms were fever (87.5%), severe headache (56.2%), facial swelling (56.2%), watering of eyes (56.2%), cough (31.2%), respiratory distress (18.7%) and pain abdomen (12.5%). Suspected patients were evaluated by computerized tomographic (CT) scan/magnetic resonance imaging (MRI), bronchoalveolar lavage (BAL) and biopsy, and the diagnosis was confirmed by culture. Of the 16 patients studied, nine had rhinocerebral mucormycosis, five had pulmonary mucormycosis and one case each had infection at the graft anastmosis site and disseminated mucormycosis. Early and intensive treatment with liposomal amphotericin-B was instituted in all patients, and extensive debridement was performed in addition in 11 cases, and one patient was subjected to graft nephrectomy; 10 patients (62.5%) survived. Our study suggests that rhinocerebral is the most frequent site of mucormycosis and it can occur very early or late in the post-transplant period. Early diagnosis and combined surgical debridement and parenteral liposomal amphotericin-B along with reduction of immunosuppression improve the patient survival.

High mortality in critically ill patients infected with 2009 pandemic influenza A (H1N1) with pneumonia and acute kidney injury

Patients infected with H1N1 virus may develop pneumonia and acute kidney injury (AKI). To determine the epidemiological characteristics, clinical features, management and out-comes of patients with confirmed H1N1 complicated by pneumonia and AKI and treatment with oseltamivir and to identify the prognostic indicators, we studied all the patients with a confirmed diagnosis of H1N1 infection with pneumonia and AKI, using real-time reverse transcriptase-polymerase chain reaction (RT-PCR) assay, between October 2009 and March 2010. H1N1 infection was confirmed in 20 patients with pneumonia and AKI; the mean age was 42.8 ± 18.2 years and 12 (60%) of the patients were males. Eleven patients were between 15 and 50 years of age, and 15 had preexisting medical conditions. All patients had fever, cough, dyspnea or respiratory distress, increased serum lactate dehydrogenase levels, pneumonia and AKI. Fifteen (75%) patients required mechanical ventilation and 14 (70%) died. None of the health care workers developed influenza-like illness, when they received oseltamivir prophylaxis. Mortality was associated with higher Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment score (SOFA), Multiple Organ Dysfunction Score (MODS), XRChest score, in addition to requirement of inotrope, ventilator support, renal replacement therapy (RRT), and presence of underlying risk factor for severe disease.

Post-exposure prophylaxis for H1N1 with oseltamivir in renal allograft recipient--safe and effective without any immunosuppresive drug interaction

Kidney transplant recipients are at a high risk for H1N1 infection associated complications during the current pandemic. Prevention of infection by immunization, together with early recognition and prompt antiviral treatment are critical. Post-exposure prophylaxis of H1N1 with oseltamivir was safe, effective and well tolerated to prevent H1N1 influenza A virus infection in newly transplanted renal allograft recipient receiving triple immunosuppression without any interaction with tacrolimus level. Oseltamivir was effective for post-exposure prophylaxis of H1N1 in close contact.