TRANSMISSION OF TUBERCULOSIS BY KIDNEY DONATION

Vanessa dos Santos Silva, Isis de Figueiredo Alfredo Guimarães, Ana Paula Maia Baptista, Marina Pontello

Cristelli, Tainá Veras de Sandes-Freitas, Marcello Franco, Hélio Tedesco-Silva Junior, José Osmar Medina-Pestana

Hospital do Rim e Hipertensão-Fundação Oswaldo RamosUniversidade Federal de São Paulo

Disciplina de Nefrologia

São Paulo Brasil

Hospital do Rim e Hipertensão

Introduction

The incidence of tuberculosis among kidney transplant patients is about 0.35 to 15% worldwide and around 1.71% in Brazil.

 The risk of TB in renal transplant patients is 20 to 30 times greater than in the general population, the implication being high morbimortality.*

The tuberculosis reactivation after transplantion is the most common presentation among transplant recipients, but transmission through the transplanted allograft has been reported in up to 4% of cases.**

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* . Currie, Andrew C. and cols. Transplantation. 2010 Oct 15;90(7):695-704.** Singh,N. and cols. Clinical Infectious Deseases. 1998 Nov;27(5):1266-77

Report two cases of probable transmission of tuberculosis by kidney transplantation

Hospital do Rim e Hipertensão

Objective

Case Report

Donor:

-17 years,

-Meningococcal meningitis, HIV negative

-Has evolved to brain death after 23 days of hospitalization. 

-He had persistent fever despite antibiotic therapy.

-There was no history of illness or contact people with

tuberculosis; his chest radiography was normal.

-Kidneys and liver were donated and transplanted.

Case Report

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  Receptor 1 Receptor 2

Gender Female Male

Age (y) 14 51

Imunossupression Azatioprine+ Prednisone+ Tacrolimus

Azatioprine+ Prednisone+ Tacrolimus

Thimoglobulyne (induction)

N N

Delay Graft Function

N N

Symptoms begining

19 days after Tx 42 days after Tx

Time to diagnosis 77 days after Tx 62 days after Tx

Clinical manifestations

Sterile leukocyturia + allograft disfunction +

fever

Leukocyturia + fever + pulmonary involvement

Previous tuberculosis

NA N

Case Report

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  Receptor 1 Receptor 2

Imediate outcome

Uneventfull Uneventfull

TB Diagnosis

Allograft biopsy Allograft biopsy and bronchoalveolar culture

Additional Tests

Allograft scintigraphy : hypercaptation

Chest Tomography:bilateral pulmonary nodules and retroperitoneal

lymphadenopathy. Bronchoalveolar lavage culture was positive for Mycobacterium tuberculosis.

Allograft rejection during

treatment

N Probable Acute Rejection – adequate response with methylprednisolone pulse

TB Treatment *

adverse reaction

N canalicular enzymes elevation e leukopenia

Tacrolimus adjustment

increase of 3,5 times from initial dose

increase of 4 times from initial dose

*TB treatment: Coxcip4 (RIPZ)

Case Report

Recipient 3 (liver transplant recipient):

The liver was transplanted at another center.

This recipient started isoniazid prophylaxis after receiving information about possible donor’s tuberculosis infection.

He has evolved well.

Case Report

Picture 1: Chronic granulomatous inflammation, caseous necrosis with epithelioid in subcapsular region, with positive Ziehl. (hematoxylin eosin -100X)

Case Report

Picture 2: Multifocal chronic epithelioid granulomatous inflammation.(hematoxylin eosin – 100X)

Conclusions

These cases demonstrates the importance of screening for donor’s infections, especially Tuberculosis, endemic in Brazil. 

Collection of history is still the best form to suspect donor’s tuberculosis.

This report also demonstrates the importance of early diagnosis of infection in transplant patients, which may be presented like disseminated forms.

The comunication of  transmission suspicion to competent institutions was essential to avoid desease in other recipient. 

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