Infection in Renal Transplant Recipients

https://doi.org/10.1016/j.semnephrol.2007.03.006Get rights and content

Summary

Renal transplant recipients are susceptible to infection by a wide array of pathogens. Impaired inflammatory responses due to immunosuppressive therapies suppress clinical and radiologic findings engendered by microbial invasion. As a result, patients are often minimally symptomatic and evaluation and diagnosis are delayed. Specific microbiologic diagnosis is essential both for the optimization of antimicrobial therapy and to avoid unnecessary drug toxicities. Differential diagnosis is guided by knowledge of organisms commonly involved in infection in immunocompromised hosts and understanding of the limitations of prophylactic strategies. The risk of infection in the organ transplant recipient is determined by the interaction between the individual’s epidemiologic exposures and net state of immunosuppression. Epidemiology includes environmental exposures in the community and hospital, organisms derived from donor tissues and latent infections activated in the host during immune suppression. The net state of immune suppression is determined by the interaction of all factors contributing to infectious risk. Routine antimicrobial prophylaxis is aimed at common infections and unique risk factors in individual patient groups. This includes trimethoprim-sulfamethoxazole (for Pneumocystis, Toxoplasma, most Nocardia and Listeria, common urinary pathogens), perioperative (eg, anti-fungal prophylaxis for pancreas transplants), or antiviral (for herpesviruses in high risk recipients).

Section snippets

The Risk of Infection After Transplantation

The risk of infection in the renal transplant recipient is determined by the interaction of 2 factors: (1) the epidemiologic exposures of the patient including the timing, intensity, and virulence of the organisms to which the individual is exposed (Table 1); and (2) the patient’s net state of immunosuppression, a measure of all host factors potentially contributing to the risk for infection (Table 2).

Consideration of these factors for each patient allows the development of a differential

Timetable of Infection

With standardized immunosuppressive regimens, specific infections vary in a predictable pattern depending on the time elapsed since transplantation (Fig. 1). This is primarily a reflection of the changing risk factors over time including surgery/hospitalization, immune suppression, acute and chronic rejection, emergence of latent infections, and exposures to novel community infections. The pattern of infection changes with the immunosuppressive regimen (eg, pulse dose steroids or

General Considerations

The spectrum of infection in the immunocompromised host is quite broad. Given the toxicity of antimicrobial agents and the need for rapid interruption of infection, early specific diagnosis is essential in this population. Advances in diagnostic modalities (computerized tomography [CT] or magnetic resonance imaging scanning and molecular microbiologic techniques) may greatly assist in this process. However, the need for invasive diagnostic tools cannot be overemphasized. Given the diminished

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