Differential diagnosis of infection following renal transplantation
- John Vella, MD, FACP, FRCP, FASN
John Vella, MD, FACP, FRCP, FASN
- Associate Professor of Medicine
- Tufts University School of Medicine
Infections are the leading cause of morbidity and mortality in the early posttransplant period as more than 80 percent of recipients suffer at least one episode of infection in the first year. Infection and allograft dysfunction caused by rejection are closely interrelated through the use of immunosuppressive therapy . The level of overall immunosuppression used for induction therapy, maintenance therapy, and the treatment of acute rejection episodes is the major risk factor for posttransplant infection, rather than the use of a specific immunosuppressive agent .
In addition, patterns of opportunistic infections after transplantation have been altered by routine antimicrobial prophylaxis for Pneumocystis carinii (also called P. jirovecii) and cytomegalovirus (CMV). These patterns are changing due to the emergence of new clinical syndromes (such as polyoma virus allograft nephropathy) and by infections due to organisms with antimicrobial resistance. New quantitative molecular and antigen-based microbiologic assays detect previously unrecognized transplantation-associated pathogens such as lymphocytic choriomeningitis virus. These assays are used in the management of common infections such as those due to CMV and Epstein-Barr virus (EBV) .
The risk of infection is influenced by a variety of other factors including [1,4,5]:
●Environmental exposure to an infecting agent, reactivation of a previously latent infection, or (rarely) active infection transmitted with the allograft.
●Presence of indwelling catheters.
- Rubin RH. Infectious disease complications of renal transplantation. Kidney Int 1993; 44:221.
- Jamil B, Nicholls K, Becker GJ, Walker RG. Impact of acute rejection therapy on infections and malignancies in renal transplant recipients. Transplantation 1999; 68:1597.
- Fishman JA. Infection in solid-organ transplant recipients. N Engl J Med 2007; 357:2601.
- Fishman JA, Rubin RH. Infection in organ-transplant recipients. N Engl J Med 1998; 338:1741.
- Passalacqua JA, Wiland AM, Fink JC, et al. Increased incidence of postoperative infections associated with peritoneal dialysis in renal transplant recipients. Transplantation 1999; 68:535.
- Rubin RH, Wolfson JS, Cosimi AB, Tolkoff-Rubin NE. Infection in the renal transplant recipient. Am J Med 1981; 70:405.
- Bakir N, Surachno S, Sluiter WJ, Struijk DG. Peritonitis in peritoneal dialysis patients after renal transplantation. Nephrol Dial Transplant 1998; 13:3178.
- Johnson DW, Isbel NM, Brown AM, et al. The effect of obesity on renal transplant outcomes. Transplantation 2002; 74:675.
- Kamath NS, John GT, Neelakantan N, et al. Acute graft pyelonephritis following renal transplantation. Transpl Infect Dis 2006; 8:140.
- Torre-Cisneros J, Castón JJ, Moreno J, et al. Tuberculosis in the transplant candidate: importance of early diagnosis and treatment. Transplantation 2004; 77:1376.
- Tolkoff-Rubin NE, Cosimi AB, Russell PS, Rubin RH. A controlled study of trimethoprim-sulfamethoxazole prophylaxis of urinary tract infection in renal transplant recipients. Rev Infect Dis 1982; 4:614.
- Fox BC, Sollinger HW, Belzer FO, Maki DG. A prospective, randomized, double-blind study of trimethoprim-sulfamethoxazole for prophylaxis of infection in renal transplantation: clinical efficacy, absorption of trimethoprim-sulfamethoxazole, effects on the microflora, and the cost-benefit of prophylaxis. Am J Med 1990; 89:255.
- Hernandez Poblete G, Morales JM, Prieto C, et al. Usefulness of norfloxacine prophylaxis in late recurrent urinary tract infection after renal transplantation. Nephron 1990; 54:193.
- Lee I, Barton TD, Goral S, et al. Complications related to dapsone use for Pneumocystis jirovecii pneumonia prophylaxis in solid organ transplant recipients. Am J Transplant 2005; 5:2791.