Infections in kidney transplantation

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Pretransplant immunological evaluation: before the transplant, the donor as well as the recipient undergo immunological evaluation, which includes standard serological tests, testing for cytomegalo virus ( CMV), Epstein- Barr virus ( EBV), hepatitis B & C, HIV 1 & HIV 2.

EBV: is the source for infectious mononucleosis… characterized by glandular fever, pharyngitis, adenopathy. It is asymptomatic and shows sign with serological tests. EBV is also responsible for causing post transplant lymphoproliferative disease (PTLPD) which includes multiple disorders involving inappropriate B cell transformation, leading to transplant rejection. 

CMVis a member of Herpesviridae,  causes asymptomatic infections or mild flu like conditions. In immunological compromised patients,  it manifests as mononucleosis syndrome and may spread to all organs and can cause pneumonia,  hepatitis,  encephalopathy etc. Clinical representation includes… fever, arthralgia,  myalgia,  leukopenia, malaise, pneumocytitis. GUIDELINES FOR TREATMENT: for D+/R-, use of valgancyclovir 900 mg once daily beginning post transplantation for 3-6 months depending on immune suppression extent. For D-/R+, prophylaxis for 3 months before transplant by valgancyclovir is recommended.  

Tuberculosis infection status: in donors and recipients, receive PPD (purified protein derivative) skin test to ascertain TB status. 

Vaccination: live attenuated vaccines can be used pretransplant,  but not after the transplant as patient becomes immune compromised.  Inactive influenza vaccine is recommended before  or after transplant.  HPV vaccine is given to patients prior transplant,  who meet the indications of it, or if not before surgery, then continue 3-4 months after.

UTIs: (urinary tract infections) are very commonly seen. It increases mortality and graft rejection.  Common pathogen is E.coli.  For this purpose,  an empirical antibiotic therapy is done. Empirical therapy along with oral fluoroquinolones,  amoxi-clav,  or an oral 3rd generation Cephalosporin is recommended. 

Pneumocystis jivrovecii:  a fungus, in nature, causes respiratory tract infections.  Treatment recommended by American Society of Transplantation is prophylaxis with  SMX-TMP usually given as a double strength tablet three times weekly or as a single strength tablet once daily for at least 6 months after transplantation.  

Reference: 1. Mata AJ, Smith JM, Skeins MA, et al. OPTN/SRTR 2012 annual data report: kidney. Am J transplant. 2014; (suppl 1): 11-44. 

2. American Society of Transplantation Infectious Diseases Community of Practice. 

3. Abott KC , Swanson SJ, Richter ER,  et al. Late Urinary tract infection after renal transplantation in the United States.

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