Developing world perspective of posttransplant tuberculosis: morbidity, mortality, and cost implications

Naqvi, Anwar; Rizvi, A; Hussain, Zafar; Hafeez, S.; Hashmi, Altaf; Akhtar, F.; Hussain, Manzoor; Ahmed, Ejaz; Akhtar, Sohail; Muzaffar, Rana; Naqvi, Rubina

doi:10.1016/s0041-1345(00)02680-4

Cited by 32 publications

(30 citation statements)

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“…4 This rate is higher than rates in Europe and North America 5,7 but lower than rates in lower-income countries, such as Pakistan and India. 6,9 This confirms that susceptibility among transplant recipients is proportional to local disease prevalence. 13 Cumulative TB incidence was higher among patients using belatacept, a fusion protein containing cytotoxic T-lymphocyte associated protein 4 and the Fc-fragment of IgG1.…”

Section: Discussionsupporting

confidence: 62%

“…5,7,8 Although only a small fraction of the kidney transplant (KT) population receives INH prophylaxis, based on clinical and radiological suspicion, there is no evidence that latent TB incidence is lower in our population. [7][8][9] Yet the risk of exposure persists long after transplant, particularly in communities with high prevalence. [7][8][9] Yet the risk of exposure persists long after transplant, particularly in communities with high prevalence.…”

Section: Introductionmentioning

confidence: 99%

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Influence of epidemiology, immunosuppressive regimens, clinical presentation, and treatment on kidney transplant outcomes of patients diagnosed with tuberculosis: A retrospective cohort analysis

Viana

Cristelli

Santos

et al. 2019

American Journal of Transplantation

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Tuberculosis (TB) mortality is high among kidney transplant (KT) recipients. Although local epidemiology is an important factor, diagnostic/therapeutic challenges and immunosuppressive therapy (ISS) may influence outcomes. We analyzed the cumulative incidence (CumI) of TB in KT recipients receiving a variety of ISS with long-term follow-up. Our retrospective single-center cohort study included all KT procedures performed between January 1, 1998, and August 31, 2014, with follow-up until August 31, 2014. Induction therapy was based on perceived immunological risk; maintenance ISS included prednisone and calcineurin inhibitor (CNI) plus azathioprine (AZA), and mycophenolic acid (MPA) or mechanistic target of rapamycin inhibitor (mTORi). Thirty-four patients received belatacept/MPA. KT was performed on 11 453 patients and followed for 1989 (IQR 932 to 3632) days. Among these, 152 patients were diagnosed with TB (CumI 1.32%). Median time from KT to TB was 18.8 (IQR 7.2 to 60) months, with 59% of patients diagnosed after the first year. Unadjusted analysis revealed an increasing confidence interval (CI) of TB (0.94% CNI/AZA vs 1.6% CNI/MPA [HR = 1.62, 95% CI = 1.13 to 2.34, P = .009] vs 2.85% CNI/mTORi [HR = 2.45, 95% CI = 1.49 to 4.32, P < .001] vs 14.7% belatacept/MPA [HR = 13.14, 95% CI = 5.27 to 32.79, P < .001]). Thirty-seven (24%) patients died, and 39 (25.6%) patients experienced graft loss. Cytomegalovirus infection (P = .02) and definitive ISS discontinuation (P < .001) were associated with death. Rejection (P = .018) and ISS discontinuation (P = .005) occurred with graft loss. TB occurred at any time after KT and was influenced by ISS. K E Y W O R D S clinical research/practice, complication: infectious, immunosuppressant -fusion proteins and monoclonal antibodies: belatacept, infection -mycobacterial, infection and infectious agents, infectious disease, kidney transplantation/nephrology

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Section: Discussionsupporting

confidence: 62%

Section: Introductionmentioning

confidence: 99%

Influence of epidemiology, immunosuppressive regimens, clinical presentation, and treatment on kidney transplant outcomes of patients diagnosed with tuberculosis: A retrospective cohort analysis

Viana

Cristelli

Santos

et al. 2019

American Journal of Transplantation

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“…Data from renal transplantation suggest a high LTBI burden in India, and the prevalence of post–renal transplant TB varies from 13.3% in India to 15.2% in Pakistan . The prevalence of LTBIs in LTRs in India is unknown; to the best of our knowledge, this is the first study of LTRs from a high‐prevalence area.…”

Section: Discussionmentioning

confidence: 91%

“…The prevalence of TB among transplant recipients is linked to the local prevalence of TB, which affects the baseline tuberculin positivity rate, the attendant risk of reactivation, and reinfection rates . The prevalence of post–renal transplant TB varies from 13.3% in India to 15.2% in Pakistan . Data on the prevalence of LTBIs and the prevalence of TB in LTRs are not available for India and other high‐burden countries.…”

mentioning

confidence: 99%

Tuberculosis in liver transplant recipients: Experience of a South Indian liver transplant center

et al. 2014

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Tuberculosis (TB) is a serious disease for liver transplant recipients (LTRs). Data on post-liver transplant TB from high-burden countries are scant. The aims of this study were to describe the prevalence of TB in LTRs from a high-prevalence area and to analyze the risk factors for the development of post-liver transplant TB. We performed a retrospective review of our database and a case-control study of identified cases with TB and age-matched LTRs without TB. The overall prevalence of TB in LTRs was comparable to the prevalence of TB in LTRs from low-prevalence countries (5/214 or 2.3%). A low rate of interferon-g release assay (IGRA) testing before liver transplantation was observed (68/214 or 31%). Most patients were screened clinically and with chest radiography alone before transplantation. TB developed variably after transplantation [median 5 72 days, interquartile range (IQR) 5 534 days]. The presentation was mostly extrapulmonary and/or disseminated (4/5 or 80%). When cases with posttransplant TB were compared with matched healthy LTRs, the presence of unexplained granulomas in explants (2/5 or 40%, P 5 0.01) was the only factor associated with the development of TB. When all explants showing granulomas were reviewed, TB (52.9%) remained the most common cause; however, in almost half (47.1%), other attributable causes were found. Patients were treated with a standard daily regimen for a median of 12 months (IQR 5 7.5 months). Posttransplant TB was associated with a high mortality rate (2/5 or 40%). In conclusion, we observed a low prevalence of TB in LTRs from a highprevalence region. The presence of granulomas suggestive of TB in liver explants warrants isoniazid prophylaxis in the absence of disease. Post-liver transplant TB is associated with a high mortality rate. The roles of routine IGRA testing and isoniazid prophylaxis in a high-prevalence setting urgently need to be studied. Tuberculosis (TB) continues to be a global scourge. India has the highest TB burden and accounts for approximately one-fifth (21%) of the global disease burden. It is estimated that approximately 40% of the Indian population is infected with the TB bacillus, and the prevalence of smear-positive pulmonary cases remains approximately 75/100,000.

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“…In Pakistan, the average cost of immunosuppression and drug monitoring in a patient without TB is 2000 US$ annually, which becomes 5000 US$ annually for a renal transplant recipient who has developed TB (50). In Pakistan, the average cost of immunosuppression and drug monitoring in a patient without TB is 2000 US$ annually, which becomes 5000 US$ annually for a renal transplant recipient who has developed TB (50).…”

Section: Discussionmentioning

confidence: 99%

Tuberculosis in Renal Transplant Recipients: The Evidence for Prophylaxis

Currie

Knight²,

Morris³

2010

Transplantation

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Both randomized and nonrandomized studies support the value of isoniazid as TB prophylaxis in renal transplant recipients at risk of active infection. Clinicians should consider prophylaxis in renal transplant recipients in endemic areas or in recipients in nonendemic countries who are at risk. However, the evidence for the benefit of isoniazid prophylaxis in renal transplantation is not robust and there is still a need for a large multicenter trial of isoniazid prophylaxis in kidney transplantation in an endemic area.

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Developing world perspective of posttransplant tuberculosis: morbidity, mortality, and cost implications

Cited by 32 publications

References 4 publications

Influence of epidemiology, immunosuppressive regimens, clinical presentation, and treatment on kidney transplant outcomes of patients diagnosed with tuberculosis: A retrospective cohort analysis

Influence of epidemiology, immunosuppressive regimens, clinical presentation, and treatment on kidney transplant outcomes of patients diagnosed with tuberculosis: A retrospective cohort analysis

Tuberculosis in liver transplant recipients: Experience of a South Indian liver transplant center

Tuberculosis in Renal Transplant Recipients: The Evidence for Prophylaxis

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