Risk factors and clinical outcomes of tuberculosis among kidney transplant recipients in high endemic country

Abstract

Background: Tuberculosis (TB) is considered as a challenge issue in solid organ transplant recipients because of high morbidity and mortality. Active TB after transplant mostly occurs from reactivation of latent infection. Understanding risk factors and clinical information of TB may provide an appropriate prevention and treatment strategies in this specific patient population, however data from high endemic area is scarce.Methods: A matched single-center, case-control study was conducted in our institute. Cases were defined as newly diagnosed confirmed or clinical active TB in patients who underwent kidney transplant (KT) between April 1992 and October 2018.For each case, 5 controls were matched by age and sex. Risk factor associated with TB was determined using univariate and multivariate conditional logistic regression.Results: Between study period, KT was performed in 787 patients. Twenty-seven patients (3.43%) were diagnosed with active TB including 20 confirmed and 7 clinical diagnosed cases. The global incidence of TB in our population was 315 cases per 100 000 patients per year. Among 27 cases, pulmonary involvement was the most common (48.1%) followed by disseminated (18.5%), extrapulmonary (14.8%), pleura (11.1%) and pleuropulmonary (7.4%) TB. Allograft rejection was significantly associated with active TB (P < .001). The median onset duration of infection was 17 months (IQR, 4-59 months) after KT. Twenty-four (88.9%) patients received rifampicin containing regimen for treatment with median duration of 10 months (IQR, 6-12 months).All patients were cured after complete treatment, however those with TB remained having unfavorable outcomes including higher all-cause mortality and graft loss.Conclusions: Incidence rate of TB in KT recipients is higher than normal population.Allograft rejection was identified as a significant risk factor. Increase unfavorable outcomes including graft loss and mortality were also observed among patients with TB.

Incidence rate of active tuberculosis in solid organ transplant recipients: Data from a nationwide population cohort in a high‐endemic country

“…Our first analysis comparing TB involvement sites between SOT recipients and non‐SOT individuals showed that the TB cases involving only extrapulmonary organs were similar between the two groups ( p = .174). The SOT recipients had a significantly higher frequency of disseminated TB, including simultaneous involvement of pulmonary and extrapulmonary organs, compared to the non‐SOT population as well as a high rate of pulmonary TB (71%), which was compatible with previous non‐comparative reports; however, our study showed a lower rate of extrapulmonary lesions and cases of disseminated TB 10,13,15,20,36,42,43,47 . In this study, the lymph node was the most common site of extrapulmonary TB.…”

“…Generally, OKT3, T‐lymphocyte depleting antibodies, or a combination of mycophenolate mofetil and tacrolimus (compared to a combination of azathioprine, cyclosporine, and prednisone) may be associated with a higher risk of TB in SOT recipients based on general risk factors for other opportunistic infections 5,9,10 . Two studies have shown that cyclosporine for renal transplants may be related to earlier onset post‐SOT TB compared to recipients using azathioprine and prednisone, but not to a higher frequency of TB 10,36 . Our data showed that the use of ATG or azathioprine was associated with a 1.5‐ or 4‐fold higher adjusted OR, respectively, of SOT recipients developing TB.…”

“…5,9,10 Two studies have shown that cyclosporine for renal transplants may be related to earlier onset post-SOT TB compared to recipients using azathioprine and prednisone, but not to a higher frequency of TB. 10,36 Our data showed that the use of ATG or azathioprine was associated with a 1.5-or 4-fold higher adjusted OR, respectively, of SOT recipients developing TB. Because of small TB cases in recipients with azathioprine use, further study will help to exam the causal relationship between azathioprine and TB risk.…”

“…The case definitions of active TB in the Korean Tuberculosis Surveillance System are compatible with the WHO criteria 34 . Disseminated TB was defined as the involvement of ≥2 non‐contagious organs or miliary TB (ICD‐10 code A19) 12,28,34–36 . Patients who had ever received ≥3 anti‐TB drugs, including isoniazid and medications in the rifamycin group, in the 12 months post‐SOT were defined as having recurrent, relapsed, or refractory TB infection 34,37 .…”

Latent tuberculosis infection and kidney transplantation

“…The incidence rate of tuberculosis (TB) in kidney transplant (KT) recipients is higher than that in the normal population, and it is associated with unfavorable outcomes including graft loss and mortality 1 . Screening for latent TB (LTBI) in KT candidates can be accomplished by a thorough clinical history and physical examination, chest radiography, and specific tests, including tuberculin skin test (TSTs) and/or interferon gamma release assays (IGRAs).…”