Renal transplantation in leprosy.

Abstract

This is the first report of renal transplantation in a patient with lepromatous leprosy although renal failure is an important cause of death in these patients (Brusco and Masanti, 1963;Desikan and Job, 1968;Hart and Rees, 1967).The deficiency of cell-mediated immune response in patients with lepromatous leprosy results in a prolongation of survival of allogenic skin grafts (Heart -and Rees, 1967;Turk, 1970;Han et al., 1971 He was now treated initially with dansone at a dose of 1 mg dailv and the prednisolone was increased to cover the lepra reaction. After initial improvement he developed a further reaction and his therapy was changed to clofazimine. On a dose of 300 mg daily his skin lesions regressed ranidly although he developed a bright red pigmentation of his skin.He remained well until December 1970, when he was readmitted with deterioration of renal function coincident with a further lepra reaction. His creatinine clearance was 5-2 ml/min and a renal biopsy showed the appearances of a chronic rejection process. He was re-established on outpatient haemodialysis. Three months later he developed pneumonia with a cavity in the apex of the lower lobe of the left lung. This was assumed to be tuberculous and he was treated with antituberculosis therapy. He had a severe lepra reaction with rifampicin, but this improved by changing to isoniazid and PAS. However, he then developed a cholestatic jaundice and died a week later, four years nine months after renal transplantation.At necropsy changes affecting many tissues and organs were found. There was a papular rash mainly on the trunk and upper limbs. Some papules contained large clusters of vacuolated cells (lepra cells) in the dermis around vessels and nerves but in none of these cells were any acid-fast bacilli found. Macroscopically many organs were a lilac pink colour which was more noticeable after fixation in a formalin-saline solution. This discoloration, although affecting the stomach, duodenum, and particularly the entire ileum, was conspicuously absent in the greater part of the jejunum. Klebsiella aerogenes was cultured from the lower lobe of the left lung which was uniformly consolidated. No organisms were isolated from a cavity at the apex of this lobe in which there was caseation. Cytomegalovirus was grown from lung tissue and inclusion bodies typical of this virus were seen both in the lungs and submandibular salivary gland. The heart was enlarged (435 g) due mainly to left ventricular hypertrophy and was partly covered by a fibrinous pericarditis. The liver was engorged and many lobules included centrilobular cholestasis. The biliary tract was patent and normal. An abscess from which no micro-organisms were identified replaced the distal third of the body of the pancreas. Both testes had lost their septate pattern and included ill-defined areas of firm grey fibrous tissue. Their tubules were necrotic and the epididymes thickened.Both the patient's own kidneys were equally small with finely and evenly granular surfaces. Microscopically in both kidn...

Six cases of leprosy associated with allogeneic hematopoietic SCT

“…According to the reported cases of patients with previously treated or current leprosy immediately before renal transplantation [8][9][10][11][12][13][14][15][16] and the fourth, fifth and sixth cases related here, leprosy did not appear as a contraindication for transplantation. Moreover, considering that de novo infection could be controlled by specific treatment in the majority of the cases of renal, [8][9][10][11][12][13][14][15][16] heart 17,18 and SCT, it seems that leprosy before transplantation is not a contraindication for the procedure.…”

“…Two patients had active lesions at the time of transplant and three relapsed at 14, 23 and 24 months post transplant. 8,10,11,13 The remaining 11 cases, including the two that occurred in heart transplant recipients, presented with de novo opportunistic mycobacterium infection from 5 months to 12 years after transplantation. 9,12,[14][15][16][17][18] Unlike SCT, in solid organ transplants (SOT), no conditioning regimen is used and post transplant immunosuppressive drugs are continued for life, in different doses and schedules, to prevent rejection or to treat episodic rejection of the transplanted organ, and no GVHD is expected to occur.…”

“…Leprosy has been described in association with kidney or heart transplantation [8][9][10][11][12][13][14][15][16][17][18] and with other immunosuppressive conditions like AIDS and cancer, [19][20][21] but not with SCT. In the cases we presented, this association occurred like de novo opportunistic infection (cases 1-3), reactivation of the disease after SCT (case 4) and simultaneous occurrence of a potentially transplantable disease with leprosy before SCT (cases 5 and 6).…”

“…Moreover, considering that de novo infection could be controlled by specific treatment in the majority of the cases of renal, [8][9][10][11][12][13][14][15][16] heart 17,18 and SCT, it seems that leprosy before transplantation is not a contraindication for the procedure.…”

“…[28][29][30][31] In the literature, there are 18 cases of leprosy in renal transplant recipients and two cases in heart transplant recipients. [8][9][10][11][12][13][14][15][16][17][18] Nine renal transplant recipients were infected with M. leprae before transplantation. Two patients had active lesions at the time of transplant and three relapsed at 14, 23 and 24 months post transplant.…”