IDN - Infections after renal transplantation in India

Abstract
Infections occurring after transplantation account for half the deaths in post transplant patients in India. The spectrum of infections, their chronological occurrence, and the risk factors are different from that of developed regions. The diagnostic and therapeutic protocols are adapted to the different medical and socio-economic environment. Tuberculosis affects 10% to 15% of renal allograft recipients; the risk is twofold and fourfold greater in those with hyperglycemia and chronic hepatitis, respectively. Pretransplantation tuberculosis is predominantly located in the lymph nodes, whereas after transplantation, the disease is often disseminated and manifested earlier due to cyclosporine therapy. Gastric juice smears and cultures for Mycobacterium tuberculosis were found to be useful tests in this group. Primary drug resistance to this organism was a problem. Isoniazid prophylaxis offered some protection from tuberculosis but was limited in the high-risk population with hepatitis. The prevalence of deep mycoses was 3.8% to 6.1% and was associated with 70% mortality. Pneumocystis carinii pneumonia emerged after 1991. Nocardiosis occurred earlier in patients who received cyclosporine and was manifested frequently, along with tuberculosis and other infections. Chronic liver disease affected 30% of patients and caused 8% of deaths. It was an important comorbid factor in patients with serious infections. Hepatitis B virus was seen in 40% of patients and hepatitis C virus in 15%. Cytomegalovirus infection was found in 20% of patients. Plasmodium falciparum infected 22.5% of renal transplant patients in western India and produced acute renal failure in 60%. Most malignancies encountered in India have had a presumed viral origin. The pattern of infections changes as immunosuppressive protocols vary and as the use of hepatitis B vaccine, hepatitis C virus screening, erythropoetin, and chemoprophylaxis becomes the standard practice in India

The first successful renal transplantation in India was performed in 1971 at the Christian Medical College (CMC), Vellore. Since then, 2400 renal transplantations, mostly from living related donors, have been performed. This centre draws patients from all over India, Bangladesh, Nepal, Bhutan and Sri Lanka. For more than a decade, an estimated 3,000 renal transplantations are performed in India annually. The experience of major transplant centres in India is reflected in the large experience of CMC, and regional differences are high- lighted.

In tropical developing regions, posttransplant infections claim more lives than graft failure from rejection or cardiovascular disease. The large southern Indian experience is no different. The risk for death doubles over a 10-year period if there is a major infection. Eighty percent of the transplant recipient deaths in CMC are associated with infections, and this is likely true in other hospitals in the country. Fifty percent of all transplant recipient deaths are primarily caused by infections in our cohort of 2100 transplant recipients. The post-transplantation survival rates without major infections were 93%, 82%, 79%, and 77%, whereas with one or more major infective illnesses, they were 85%, 67%, 62%, and 60% at 1, 5, 10, and 12 years, respectively.

A Timetable for Tropical Post transplantation Infections
Published accounts on the chronological appearance of various infections have helped physicians target investigative protocols and empirical treatment based on the probability of disease at varying intervals after transplantation. The balance of exposure to infective agents and the net state of immunosuppression determine the risk for infection. The lifestyle of the majority of the population in the tropics, with over-crowding, high prevalence of endemic infections, hepatitis, and undernutrition, is different from that of the developed western world, although the immunosuppressive protocols are similar. Therefore, one expects the profile of posttransplantation infections to be different from that described for the developed world.2

We studied the chronological occurrence of infections in 920 living related transplant recipients at CMCH from 1986 to 1994.3 They received prednisolone plus azathioprine (PRED + AZA) immunosuppression until 1989 and thereafter PRED + AZA + cyclosporine (CsA) or PRED + CsA (CsA at a higher dose). CsA was discontinued at 1 year in most patients. Patients were available in Vellore for the first 6 months and later at months 9 and 12 and when clinically required. The follow-up was 100% at 6 months, 80% at 9 months, and 95% at 12 months. Subsequently, only a clinic follow-up of 40% and correspondence with another 20% of patients with a specific need or on a routine yearly basis was possible.

Rubin categorised infections as those occurring within the first month after transplantation, 2 to 6 months, and thereafter. The first period included surgery-related or urinary tract infections (UTIs). The majority of infections caused by Pneumocystis carinii were seen between 1 and 12 months after transplantation, whereas cryptococcal infections occurred much later, as also seen in Rubin’s schema.Deep mycoses of various types and nocardiosis were seen, but the presence of such different risk factors as renal failure, liver disease, hyper-glycaemia, extra immunosuppression, or leucopenia did not determine their time of manifestation before or after 6 months, as described in the analysis of Rubin.2 We have been able to show that CsA-treated patients develop tuberculosis (TB) earlier than patients receiving PRED + AZA. Varicella zoster has a bimodal incidence among the staff and students of CMCH, but seven of eight transplant recipients who developed varicella zoster had it later than 6 months after transplantation. Five patients manifested clinical leprosy an average of 71 months after transplantation, none of whom had apparent disease at surgery.4

The timetable for tropical posttransplantation infections is highlighted by the chronological occurrence of TB in patients with and without CsA therapy and provides information on varicella zoster and leprosy. The 6-month milestone of step down in immunosuppression did not demarcate the onset and susceptibility to infectious disease in our patients. This reflects an altered susceptibility pattern, possibly because of coexisting infections in the immunosuppressed patient of the tropics, together with a greater prevalence of endemic infections.

Urinary Tract Infections
UTIs are predominant among infections in the first month posttransplantation and commonly account for most of the bacteremias in the first month. To study whether a 2-week chemotherapy regimen is adequate to prevent posttransplantation UTI, patients were randomised into two groups to receive appropriate antibiotics for 2 weeks or 6 weeks. The cure rate was 82% in both groups, and the relapse rates were 8% in the 2-week treatment group and 4% in the 6-week treatment group.5 Currently, we treat UTIs only for 2 weeks. Reflux nephropathy caused end-stage renal failure in 4.5% of transplant recipients and was associated with multiple or persistent UTIs requiring long-term chemoprophylaxis.6
Persistent UTIs were seen in 6.5% of the transplant recipients on follow-up despite normal urological evaluations and the absence of donor LMs. These patients continued to have persistent asymptomatic UTIs, which were left untreated after the initial 8 weeks without complications.7

Pneumocystis carinii Pneumonia
Pneumocystis carinii pneumonia (PCP) in a renal allograft recipient made its first appearance in 1991. Since then, all prior postmortem lung tissue of renal transplants (n = 71) and subsequent samples (n = 32) were reevaluated.8 There was infection caused by Pneumocystis spp. in 4 of the 32 autopsies performed between 1991 and 1994 and none of the 71 autopsies performed before. In addition, there have been eight confirmed cases of PCP and one case of a postmortem lung biopsy after 1991. Co-trimoxazole prophylaxis has been used for the first 6 months posttrans- plantation since 1995 successfully. The appearance of PCP in our hospital is akin to its increasing incidence in cancer patients in the west, which could both be linked to the occurrence of the AIDS epidemic, bringing in its train large numbers of patients with PCP.

Mycobacterial Infections
Mycobacterial infections are a major cause of morbidity and mortality in our experience, with an incidence of 10% to 15% in the posttransplantation population. The incidence in the general population is 1% to 2%. Most patients with posttransplantation TB have a pulmonary focus when chest radiology is usually suggestive but not confirmatory.
We used sputum and gastric aspirate examination for TB in 213 renal allograft recipients suspected of having pulmonary TB. One hundred thirty-two patients had sputum tests, of which 14 showed acid-fast bacilli (AFB). Of the 118 patients who tested negative with sputum, 25 patients had gastric aspirates, of whom 9 patients were found to be positive for AFB. Eighty-one of those patients without sputum had gastric juice tested, and 14 patients were positive. Bronchoalveolar lavage (BAL) was performed on a small group of 17 patients and yielded three more positive specimens. It is of interest that in patients with negative test results of sputum, gastric juice examination yielded positive results. BAL did not add to the number of positive isolates in this group, although it did in the group without sputum who had negative gastric juices. Also, patients with a chest radiograph suggestive of TB had a higher yield of gastric juice positive for AFB.9 We use and recommend this simple screening protocol for using gastric juice for suspected pulmonary TB in patients who have no sputum or negative sputum tests and subject these specimens to culture and sensitivity tests. Routine bronchoscopy and BAL for every patient who does not produce sputum but is suspected of having pulmonary infection is expensive, time consuming, and beyond the reach of most hospitals in this country.

The incidence and impact of TB were studied prospectively on an extended cohort of 1,145 patients from 1986 to 1997. The average annual incidence of pretransplantation TB was 8.7%, whereas after transplantation, the incidence of TB was 12.3%. The incidence of posttransplantation TB was reported to be a similar 11.8% from Chandigarh in northern India.10 One hundred, 141, and 6 patients had pre- transplantation TB, posttransplantation TB, and tu- berculous iliac lymph nodes found at transplant surgery, respectively. The risk of post TxTB on cyclosporine (CsA) was 2.5 (p=0.0311) and 1.9 (p=0.0430) times at £ 6 and £ 12 months respectively compared with patients on PRED+AZA. The cumulative survival rates among transplant recipients without TB at 6 months and 1, 5, and 8 years were 94%, 92%, 77%, and 73%, and for those with TB, were significantly less at 92%, 90%, 67%, and 59%, respectively. The occurrence of TB before or after transplantation increased the risk for death 1.3 and 1.6 times, respectively. Although TB was not associated with graft loss, it was believed to have directly caused death in 22.5% of the patients with TB. The risk for TB was twofold and fourfold greater in patients with hyperglycaemia and chronic hepatitis, respectively11.

We also analysed the genetic predisposition for TB in the immunosuppressed population by comparing those developing TB (n = 84) with those not developing TB (n = 496) over a 5-year period from 1989. HLA A68 (28)/A69 (28) locus appeared to predispose toward posttransplantation TB in the Indian population. 12

Primary drug resistance to Mycobacterium tuberculosis is a dreaded complication, particularly in the immunosuppressed patient. From 1987, we have been observing the drug sensitivity profiles of those strains infecting our posttransplantation patients.13 We found emerging rifampicin resistance from 1991 in one, two, and three patients annually. In 1993, two of four of these patients had multidrug resistant organisms. This is a cause for concern because it may indicate a large reservoir of drug-resistant patients in the community in the face of the increasing AIDS population in the country. We currently recommend comprehensive drug sensitivity testing of mycobacterial isolates and initial treatment with four drugs until sensitivity reports are available.

Primary Isoniazid prophylaxis
Primary isoniazid (INH) prophylaxis has been recommended for all renal transplant recipients based on logic, rather than scientific tests of effectiveness. We evaluated the safety and efficacy of INH prophylaxis in a randomised double-blind trial of patients undergoing hemodialysis and continued after transplantation.14 The drug or placebo was continued after transplantation for a period of 1 year. These patients were followed up for a year further. Those found to have hepatitis and TB were excluded. Patients with clinical hepatitis, TB, drug-induced psychosis, or drug rash were removed from the trial. Intention-to-treat analysis was performed and included 33 and 32 patients developing hepatitis in the INH placebo groups, respectively, after censoring those who defaulted, died, or developed drug side effects. The end point was the development of TB. In addition, those who developed hepatitis were censored from the on-treatment analysis. The intention-to-treat analysis showed a similar incidence of TB in both groups, whereas the on-treatment analysis (excluding patients developing hepatitis) showed a greater proportion of patients without TB in the INH group. This study for the first time showed INH offers some degree of protection against TB, although its use was limited in the high-risk population with hepatitis. Therefore, despite a 5% primary drug resistance to INH in the general population, INH prophylaxis appears to be justified but cannot be used in many patients.

Systemic mycoses (SM)
Systemic mycoses have been reported to be associated with high mortality in India by Chugh et al. 15 Data from 1476 primary renal transplant recipients was prospectively recorded from 1986 to 2000 from our center. Cumulative incidence, time of occurrence of SM, risk factors for SM, and its outcome were analyzed. Postmortem findings of 30 patients with SM were also studied.
A total of 110 episodes of SM occurred in 98 patients. The fungal genera Aspergillus, Cryptococcus and Candida constituted 61% of pathogens. In 45% of cases the lesions were localized to the lungs. Cryptococcus diminished with advent of cyclosporine (CsA) immunosuppression.16 Incidence of Pneumocystis decreased with cotrimoxazole prophylaxis. Aspergillus and Candida incidence density increased in the last 5 years of the study. Underlying CMV disease caused more than a 5-fold and chronic liver disease a two-fold increase in SM. Tuberculosis with or without nocardiosis was a significant co-infection. CsA was associated with nearly a four-fold risk of SM < 6 months as compared to PRED+AZA therapy. Overall, the probability of survival with SM was 73.4%, 60.8%, 39.5% and 25.6% and without SM was 92.5%, 87.5% 80.0% and 75.5% at 1, 2, 5 and 10 years respectively (P<0.0001). Extended Cox Model showed SM, CMV disease, chronic liver disease (> 3 years), diabetes mellitus, Pred+AZA immunosuppression (> 2 years) had 3.5, 1.8, 1.7, 1.6, 2.1 times the risk respectively for death as compared with those who did not have those risk factors.
There has been a recent change to a predominance of Aspergillus in SM and the incidence of Candidiasis has increased in the last five years. The risk factors are CMV disease, chronic liver disease, hyperglycemia; tuberculosis as an important co-infection. CsA use was seen to increase early SM. The risk factors for death are SM, CMV disease, chronic liver disease (> 3 years), diabetes mellitus and Pred+AZA immunosuppression (> 2 years). Overall, the probability of survival with SM was poor, however recently survival has improved with prompt diagnosis and treatment.

Nocardiosis
Of the 1968 patients who received primary renal allografts at CMCH 27 patients developed nocardiosis over 30 years. Early nocardiosis (£ 2 years) was associated with chronic liver disease and the use of cyclosporine as compared with its later occurrence (>2 years). Seventeen patients (63%) had two or more associated post-transplant infections, of whom 10 had tuberculosis. Mortality in these patients was associated with chronic liver disease.17

HBV and Hepatitis C Virus Infections
Chronic liver disease affects 10% of our patients, leading to liver cell failure, hepatocellular cancer, increasing susceptibility to infection, and altered metabolism of drugs, and precludes the effective use of essential drugs for prophylaxis and immunosuppression. Liver cell failure directly accounted for 8% of the deaths in our cohort and was a significant co-morbid factor in those succumbing to sepsis. Most patients who died in the hospital with significant liver pathological states had hepatotropic viral infections.18

We studied 406 renal transplant recipients from 1994 to June 1998 who spent an average of 3 months undergoing hemodialysis to evaluate the epidemiological characteristics of HBV and hepatitis C virus (HCV). Pretransplantation tests showed HBV positivity in 49 patients (12.1 %), DNA/c antigen positivity in 6 patients (1.5%), and core antibody/surface antibody positivity in 107 patients (26.4%). Of the 244 patients negative for HBV, 93 seroconverted after vaccina- tion. Posttransplantation tests showed HBV positivity in 45 patients (11%), DNA/e antigen positivity in 19 patients (4.6%), and core antibody/surface anti- body positivity in 101 patients (24.7%).19 Protective antibodies persisted in 85 of the 93 patients who seroconverted after vaccination. Markers of HBV replication trebled after transplantation, although the overall prevalence remained the same. The pretransplantation prevalence of HBV has halved from that seen a decade ago and is now largely caused by infection acquired before presenting to this hospital. One centre in India, however, has reported a lower prevalence of approximately 10% of hepatitis B surface antigen positivity.20

We prospectively evaluated the efficacy of intramuscular double-dose recombinant vaccine in a cohort of patients who entered onto the dialysis programme for 1 year.20 of 131 patients, 15 patients were infected at entry and the rest were started on a hepatitis B vaccine protocol. Only 53 patients could complete the vaccine protocol, of whom 10 patients seroconverted. Seroconversion rates were better in those who started on the vaccine programme before initiating hemodialysis. Most of those who did not complete the vaccine programme had left the dialysis programme or developed HBV infection within a short window period after arrival at Vellore.21
Subsequent research has shown that although blood transfusions administered before transplanta tion with concomitant immunosuppression to prevent sensitisation significantly impede seroconversion in those undergoing hemodialysis, frequent intradermal vaccine improves the seroconversion rates.22 HCV is the second most common cause of hepatitis in our population. Banked blood has been screened for HCV antibody in this hospital for more than 2 years, but it is expensive and not a routine practice or a mandatory test in most blood banks in the country. This is likely to become more important than HBV infection among our transplant recipients. The first report from India came from CMCH in 1992, when we tested for HCV antibodies using first- and second-generation enzyme-linked immunosorbent assay tests (Abbott Laboratories, Chicago, IL) for HCV antibodies and found a 3.03% prevalence in a sample population.23 Since 1997, HCV nested polymerase chain reaction is also available in this hospital. A 4-year review of pretransplantation tests shows a positive rate of 8% in the 225 patients tested (HCV antibody with or without HCV RNA), and after transplantation, a doubling of prevalence to 15.5%. 23 This increase occurred mostly as a result of the use of unscreened blood products and organ donors in the first half of the period of review Physical isolation of HBV- and HCV-infected dialysis patients and routine intradermal vaccination with hepatitis B vaccine has helped contain the HBV disease. Mandatory blood transfusions for possible immunologic benefit are avoided, and the medical requirement for

blood is reduced with the use of erythropoietin. HCV screening for blood was introduced in 1997 at CMCH. Donor screening for HBV and HCV has been practised since 1986 and 1997, respectively. Preemptive renal transplantation, when possible, has been shown to reduce viral infections24 and improve survival.

Cytomegalovirus Disease
Cytomegalovirus disease affects 0.6 – 1% of our renal transplant recipients. Patients receiving cyclosporine and anti T-cell antibodies are at a higher risk. CMV disease localised to the gastrointestinal system or presented with fever and leucopoenia in most. Retinal involvement was a late phenomenon. The infection is associated with a higher incidence of posttransplant tuberculosis and systemic mycoses, due to its effects on the immune system.

Parasitic Infections
Parasitic infections are commonly overlooked in transplant recipients, and this is at their peril, particularly in the tropics. From 1971 to 1999, we have seen a variety of cases with invasive and infective parasitoses: Strongyloides stercoralis (four cases), Entameba histolytica (two cases), Acanthameba spp (one case), Wuchereria bancrofti (one case), Blastocystis hominis (two cases), and Cryptosporidium spp (four cases), whereas Plasmodium vivax malaria occurred sporadically and without renal sequelae. Of these, the first four parasites produced lethal infections with dissemination and associated gram-negative sepsis within the first 6 months. Strongyloides spp hyperinfestation has thus far occurred only in one patient among the large number of CsA-immunosuppressed transplant recipients, perhaps on account of its larvicidal

Summary
I outlined the recent published experience in the field of posttransplantation infections from CMC that largely reflects the situation in the subcontinent. Infection remains the major hazard of transplantation in India. The epidemiological characteristics of various diseases and measures for better diagnosis, treatment, and prophylaxis that we studied at CMC for 15 years, are described. Many of these suggestions can be modified for wider application. Large multicentre trials of prophylaxis and treatment of posttransplantation TB are needed. The scourge of infections described here would give way to a brave new world for the transplant recipient in the tropical developing nations if multivaccine-protected, erythropoietin-treated, untransfused patients on appropriate chemoprophylactic therapy received renal transplants with induction of graft tolerance and minimal maintenance immunosuppression.

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22. Vincent L, John GT, Abraham P, et al: An intradermal vaccine protocol against hepatitis B virus in a hemodialysis population. Natl Med J India 1998, 11:48
23. Mathew CM, Jacob CK, John GT, et al: Hepatitis C virus infection in renal allograft recipients-a pilot study. Ind J Nephrol 1994, 4:1
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