Posttransplant infectious complications: a prospective study on 142 kidney allograft recipients.
ABSTRACT We evaluated the posttransplant complications resulting from infections and their association with graft function, immunosuppressive drugs, and mortality.
A total of 142 kidney allograft recipients were followed for 1 year after transplantation. The patients' status was assessed during regular visits, and data including clinical characteristics, infections, serum creatinine level, acute rejection episodes, immunosuppressive regimen, graft function, and mortality were recorded and analyzed.
Infections occurred in 77 patients (54%). The lower urinary (42%) and respiratory (6.3%) tracts were the most common sites of infection. The most frequent causative organisms were Klebsiella in 34 (24%) and cytomegalovirus in 25 patients (18%). Wound infection occurred in 7 patients (5%). The mortality rate was 7.7% and infection-related death was seen in 5 patients (3.5%) who developed sepsis. Graft loss was seen in 16 patients (11%), of whom 2 developed cytomegalovirus infection, 2 experienced urinary tract infection, and 5 developed sepsis and died. Mycobacterial and hepatitis C infections were noticeably rare (0.7% and 2.8%, respectively).
This study showed that infections are important causes of morbidity and mortality during the posttransplant period. We recommend that serologic tests be performed before and after transplantation to recognize and meticulously follow those who are at risk. In our study, high-risk patients were those with elevated serum creatinine levels who received high doses of immunosuppressive drugs. As the urinary tract is the most common site of infection, early removal of urethral catheter is recommended to reduce the risk of infection.
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ABSTRACT: Infections still represent a major clinical issue in the field of renal transplantation, impacting on graft and patient survival. Post-surgical complications in the immediate post-transplantation period, and immunosuppression (related to the use of new drugs such as mycophenolate mofetil, rapamicin, sirolimus and tacrolimus, and of increasingly aggressive immunosuppressive regimens) in later phases entail an increased risk for infection. Bacteria (in particular Enterobacteriaceae, non-fermenting Gram-negative bacilli and Enterococcus spp) and Candida spp are a frequent cause of urinary tract infection in the early post-transplantation phase. Cytomegalovirus (CMV) is a frequent infectious complication (20-60% of patients) whose risk is enhanced by mycophenolate mofetil. It can cause a variety of diseases: organ or disseminated acute disease, acute graft rejection, chronic allograft nephropathy, graft glomerulopathy, renal artery stenosis, induction of secondary bacterial or mycotic disease. Monitoring CMV antigenemia (pp65) allows a strategy based on pre-emptive therapy among patients with evidence of virological activity. BK virus (BKV) is a polyomavirus associated to various clinical syndromes in severely immunocompromised patients, such as haemorrhagic cystitis, ureteral stenosis and others. The variety and severity of infectious complications in this field mandate a multidisciplinary approach involving, next to the nephrologist and the surgeon, an infectious disease consultant and a clinical microbiologist.Giornale italiano di nefrologia: organo ufficiale della Societa italiana di nefrologia 01/2004; 21 Suppl 26:S48-52.
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ABSTRACT: Cyclosporin (CYA) is now recognized as an effective immunosuppressant to lead to a marked improvement in graft survival in organ transplant recipients. Although the incidence of infection in the CYA group has been decreased compared with that in the azathioprine group, infectious diseases in 400 kidney transplant recipients treated with CYA were noted in our single center. Treatment strategy for infectious diseases: Antibiotics and/or gamma-Globulin were administered to all recipients with bacterial infections. Aciclovir was added in recipients with herpes simplex virus (HSV) infection or varicella zoster virus (VZV) infection. Human interferon-beta (HuIFN-beta) was used in recipients who had life-threatening viral infection, especially cytomegalovirus (CMV) pneumonitis. Glycyrrhizin was used for acute hemorrhagic cystitis and nephropathy due to adenovirus (AV). Trimethoprim sulfamethoxazole and/or pentamidine were added in recipients complicated with Pneumocystis carinii (Pc) pneumonitis or in order to prevent Pc pneumonitis. Infectious diseases: One hundred and six recipients had infectious diseases 129 times in this series, seventy-six percent of all infections occurred during the first 4 months after the transplantation. Urinary tract infection (UTI), herpes zoster and pulmonary infection were the most common infectious diseases, occurring in 28.7%, 24.0% and 23.2%, respectively. Septicemia or bacteremia developed in 9 recipients, secondary to UTI in 8 and to surgical wound infection in one. Sixty-one symptomatic viral infections occurred in 57 recipients. A total of 5 recipients (1.3%) died of interstitial pneumonitis. Infectious organisms: Viral and bacterial infections were most common, occurring in 47.3% and 41.9%, respectively. Viral species detected in these recipients with the frequency were HSV 14 times, CMV 9 times, VZV 31 times and AV 7 times. 1) The incidence of viral infections in kidney transplant recipients treated with CYA is relatively high compared to bacterial infections. 2) HuIFN-beta therapy is effective in the treatment of serious opportunistic herpes virus infections, especially CMV pneumonitis. 3) Glycyrrhizin therapy is effective in the treatment of acute hemorrhagic cystitis and nephropathy due to AV and hepatic dysfunction. 4) Aerosolised pentamidine therapy is very useful for prophylaxis of Pc pneumonitis.Nippon Hinyōkika Gakkai zasshi. The japanese journal of urology 03/1989; 80(2):175-84.
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ABSTRACT: To describe the incidence and clinical characteristics of mycobacterial infection in renal transplant recipients. We retrospectively analyzed the cases of mycobacterial infection in a series of 1261 renal transplants carried out in our Unit of Renal Transplantation from 1980 to 2000. Demographic parameters and clinical antecedents such as age, cause of end-stage renal disease, time of follow-up of the graft, previous renal function and type of immunosuppression were considered. Moreover, the clinical onset, diagnostic tools, treatment policy and evolution were studied. The pathogenesis of the different types of mycobacteria isolated was also analyzed. Diagnosis was made with the Ziehl-Neelsen staining method. Culture was performed by the conventional Löwenstein-Jensen method and the Bactec-460 radiometric method. We found mycobacterial infection in 27 patients (2.1%), due to Mycobacterium tuberculosis in 20 cases, M. kansasii in five patients, and M. fortuitum in two patients. The mean elapsed time from the renal transplant was 20.5 months; the infection appeared in 18 patients during the first eight months after transplantation. The clinical onset was pulmonary infection in 17 cases (12 M. tuberculosis and five M. kansasii); five had urinary symptoms (three M. tuberculosis and two M. fortuitum); three cases of M. tuberculosis infection had abdominal symptoms; another one began with a perineal tuberculous abscess; the rest of the patients were asymptomatic. The types of specimen on which microbiological identification was carried out were, in decreasing order: sputum and/or bronchial washing/pleural aspiration, urine, feces, gastric and peritoneal fluids, bone marrow and blood. The first-line drug isoniazid had the highest resistance index in the susceptibility test. Clinical dissemination was observed in eight patients, four of whom died. Another three patients had a significant impairment in renal function, and in one of these patients an allograft nephrectomy was necessary due to a severe septic syndrome. Mycobacterial infection, mainly by M. tuberculosis, has an important impact on kidney transplant recipients, particularly during the first year after surgery. Diagnosis often presents some difficulties, and a delay in treatment represents a determinant factor for the evolution, with a risk of death or permanent damage in renal function. Therefore, early diagnosis is mandatory. When the Mantoux reaction is positive, antituberculous prophylaxis seems advisable.Clinical Microbiology and Infection 07/2003; 9(6):518-25. · 4.58 Impact Factor
Posttransplant Infectious Complications: A Prospective Study
on 142 Kidney Allograft Recipients
Gholamreza Pourmand,* Mohammadreza Pourmand, Sepehr Salem, Abdorasoul Mehrsai,
Mohsen Taheri Mahmoudi, Mohammadreza Nikoobakht, Reza Ebrahimi, Ali Saraji, Shahram
Moosavi, Babak Saboury
Urology Research Center, Division of Transplantation, Tehran University of Medical Sciences, Iran
Introduction: We evaluated the posttransplant complications resulting from
infections and their association with graft function, immunosuppressive drugs, and
Materials and Methods: A total of 142 kidney allograft recipients were followed for
1 year after transplantation. The patients' status was assessed during regular visits,
and data including clinical characteristics, infections, serum creatinine level, acute
rejection episodes, immunosuppressive regimen, graft function, and mortality were
recorded and analyzed.
Results: Infections occurred in 77 patients (54%). The lower urinary (42%) and
respiratory (6.3%) tracts were the most common sites of infection. The most frequent
causative organisms were Klebsiella in 34 (24%) and cytomegalovirus in 25 patients
(18%). Wound infection occurred in 7 patients (5%). The mortality rate was 7.7% and
infection-related death was seen in 5 patients (3.5%) who developed sepsis. Graft loss
was seen in 16 patients (11%), of whom 2 developed cytomegalovirus infection, 2
experienced urinary tract infection, and 5 developed sepsis and died. Mycobacterial
and hepatitis C infections were noticeably rare (0.7% and 2.8%, respectively).
Conclusion: This study showed that infections are important causes of morbidity
and mortality during the posttransplant period. We recommend that serologic tests be
performed before and after transplantation to recognize and meticulously follow those
who are at risk. In our study, high-risk patients were those with elevated serum
creatinine levels who received high doses of immunosuppressive drugs. As the urinary
tract is the most common site of infection, early removal of urethral catheter is
recommended to reduce the risk of infection.
KEY WORDS: kidney transplantation, infections, complications, mortality, cytomegalovirus,
urinary tract infection
Vol. 3, No. 1, 23-31 Winter 2006
Printed in IRAN
Kidney transplantation is an established,
definitive, highly successful therapy for end-stage
renal disease (ESRD) and is more widely
accessible now than in previous decades.(1,2)
However, infectious complications after kidney
transplantation are still associated with a
significant morbidity and continue to be the most
frequent cause of death during the early
immunosuppression, about 50% (6% to 86%) of all
Received May 2005
Accepted September 2006
*Corresponding author: Urology Research Center,
Sina Hospital, Hassanabad Sq, Tehran 1995345432,
Iran. E-mail: firstname.lastname@example.org
Posttransplant Infectious Complications
kidney allograft recipients develop an infection
within the first 6 months after engraftment.(2,5)
In developing countries (with rates of 15% for
tuberculosis, 30% for cytomegalovirus, and nearly
50% for bacterial infections), the spectrum of
infections, their chronological occurrence, and
their risk factors in kidney recipients seem to be
different from those in developed regions.(6,7)
Owing to the progress made in the treatment of
infections and the increasing expertise of the
transplant team, deaths resulting from infections
have decreased from 73% before 1976 to 20%
between 1994 and 1996.(1,2,7)In the United States
(1998), mortality due to infections was close to
0.3 deaths per 100 patient-years in 1998,
corresponding to 20% of deaths in all transplant
patients, and the Medicare spending during the
first year after transplantation was about US $88
000 for each patient, approximately, 20% of which
was used for the diagnosis and treatment of
Due to environmental, social, and financial
differences between countries, we assume that
posttransplant infectious patterns may be
different too; therefore, we planned this research
to investigate posttransplant
complications and their association with patients'
characteristics and transplantation outcomes.
Materials and Methods
From February 2002 to February 2004, 179
patients with ESRD
transplantation at Sina Hospital in Tehran, Iran.
They were followed for 1 year for infectious
complications and the outcomes of the kidney
All donors and recipients received a single dose
of intravenous prophylactic antibiotic 1 hour
preoperatively (ceftriaxone 1 g). All kidney
recipients received cephalothin for 4 days during
the hospital stay
sulphamethoxazole for 6 months postoperatively
The kidney allograft
retroperitoneally in the right or left iliac fossa.
The ureter was anastomosed to the recipient's
bladder. The native kidneys of the recipients were
not removed. The Foley catheter and ureteral
double J stent were removed after 7 and 40 days
of transplantation, respectively.
All patients received prednisolone (1 mg/kg/d,
tapered by 5 mg weekly), cyclosporine A (5
mg/kg/d), and mycophenolate mofetil (2 g/d).
Acute rejection was managed with antithymocyte
globulin (ATG) or pulse methylprednisolone.
Furthermore, ATG was administered as
prophylaxis in high-risk patients who had their
second or third transplantation or had positive
panel reactive antibodies and in recipients of
cadaveric kidney allograft. Blood cyclosporine
levels were checked on the seventh postoperative
day and monthly thereafter.
During the hospital stay, clinical examinations
and laboratory investigations including complete
blood cell count with differential and serum urea,
creatinine, and electrolytes were performed daily.
Urinalysis and urine culture were done twice per
week. When indicated (presence of fever,
leukocytosis, urinary symptoms, respiratory
symptoms, diarrhea, abdominal pain, tenderness
of the graft, discharge from the wound or
catheter site, elevation of creatinine level, and
decrease in the level of consciousness), one or
more of the following investigations were
performed according to the clinical status: smear
and cultures of blood, urine, throat, sputum,
synovial fluid, cerebrospinal
bronchoalveolar lavage fluid. Moreover, serologic
tests were carried
anticytomegaloviruc antibody (enzyme-linked
immunosorbent assay), cytomegaloviruc (CMV)
antigen (pp65), CMV DNA (polymerase chain
reaction), hepatitis B surface (HBs) antigen, anti-
HBc antibody, HBV DNA (polymerase chain
reaction), antihepatitis C virus (anti-HCV)
antibody (polymerase chain reaction), herpes
simplex virus (HSV), and varicella-zoster virus
During follow-up, the patients were visited
weekly for the first month, every 2 weeks in the
second month, monthly up to the sixth month,
and every 3 months thereafter. Laboratory
investigations, including complete blood cell
count with differential, serum urea, creatinine,
and electrolytes, urinalysis, and if necessary,
imaging tests such as ultrasonography of the
graft and renal radioisotope scan were carried
Although the presence of bacteriuria would
fulfill the criteria for urinary tract infection (UTI)
in kidney transplant recipients,(8)other criteria,
such as pyuria (more than 10 leukocytes/mL) and
fever, are frequently used for diagnosing UTI. For
diagnosing UTI and respiratory tract infections
(RTIs), we used the Centers for Disease Control
and Prevention (CDC) definition.(9)
Pourmand et al
infection was defined as the presence of purulent
discharge from a surgical wound (confirmed by
culture). Cytomegalovirus infection was defined
as CMV antigen detection in the recipient's
serum. The diagnosis of CMV disease was based
on the presence of clinical symptoms (fever,
involvement) and detection of CMV in clinical
samples (such as blood and bronchoalveolar
We collected postoperative data regarding graft
function (creatinine level), infectious episodes
(types and time), episodes of acute rejection,
dosage of immunosuppressive drugs, and rates of
The study was performed in accordance with
the international standards of good clinical
practice and the World Medical Association
Declaration of Helsinki
amendments,(10) and approved by the ethics
committee at Tehran University of Medical
Sciences. Meanwhile, written informed consent
was obtained from all patients.
The collected data were analyzed using the chi-
square or Fisher exact test for dichotomous
variables and the Student t test for continuous
variables. Analyses were carried out with SPSS
software (Statistical Package for the Social
Sciences, version 11.5, SPSS Inc, Chicago, Ill,
USA) and a P value less than .05 was considered
myalgia, and organ
Of 179 kidney recipients, 142 were followed for
1 year posttransplant (Table 1). The most
frequent underlying causes of renal failure were
hypertension in 51 (36%) and diabetic
nephropathy in 17 patients (12%) (Figure 1).
Overall, infections occurred in 77 (54%)
patients. The most frequent causative organisms
were Klebsiella in 34 (24%) and CMV in 25
patients (18%) (Table 2). Lower urinary tracts
(42%) and respiratory tracts (6.3%) were the most
common sites of infections (Figure 2). The
following is the description of all infectious
FIG. 1. Major causes of end-stage renal disease in kidney transplant patients
TABLE 1. Characteristics of 142 kidney allograft
Characteristics Value (%)
Female sex 50 (35)
Mean ± standard deviation 41 ± 14.47
Range 8 to 73
Posttransplant hospitalization (days)
Mean ± standard deviation
24 ± 13.12
9 to 113
Living-unrelated 120 (85)
Living-related 12 (8)
Cadaveric 10 (7)
Retransplantation 3 (2)
Positive panel reactive antibodies 1 (0.7)
Posttransplant Infectious Complications
complications evaluated in this study. Donor type
(living-related, living-unrelated, or cadaveric) was
not associated with UTI, CMV, and wound
infection, but RTIs were less common in kidney
recipients from living-unrelated donors (Table 3).
Age distribution of the patients with infectious
diseases is shown in Table 4.
FIG. 2. Posttransplant infectious complications, acute rejection, and mortality during 1-year follow-up
Number of patients
Cytomegalovirus diseaseUrinary tract infectionsRespiratory tract infections Wound infections Acute rejectionDeath
TABLE 2. Pathogens detected in infectious cases
Klebsiella 31 1 - 2 34 (24)
Escherichia coli 10 1 2 1 14 (10)
Enterococci 10 - 2 1 13 (9)
Pseudomonas aeruginosa 6 1 - - 7 (5)
Staphylococcus aureus - 1 2 1 4 (3)
Staphylococcus coagulase-negative 1 1 1 1 4 (3)
Streptococci 1 2 - - 3 (2)
Citrobacter 1 - 1 - 2 (1)
Mycoplasma - 1 - 1 2 (1)
Mycobacterium tuberculosis - 1 - - 1 (0.7)
Cytomegalovirus - - - 25 25 (18)
Hepatitis C virus - - - 4 4 (3)
Hepatitis B virus - - - 3 3 (2)
Varicella-zoster virus - - - 2 2 (1)
Herpes simplex virus - - - 1 1 (0.7)
Yeast 3 - - - 3 (2)
Aspergillus - - - 1 1 (0.7)
Candida - - - 1 1 (0.7)
Entameba histolytica - - - 2 2 (1)
Pourmand et al
Bacterial urinary tract infections. Fifty-nine
patients(42%; 33 men, 26 women) developed UTI
(Figure 2), of whom 37% and 10% were
hypertensive and diabetic, respectively (Table 5).
Sex distribution among patients with UTI was
not different from the entire group of kidney
recipients (P = .062). Thirty-eight percent of UTIs
occurred during the hospital stay. The mean time
between transplantation and the first episode of
UTI was 58.0 ± 114.5 days. The mean serum level
of creatinine at the time of UTI was 2.56 ± 2.07
mg/dL. Urinary tract infection occurred in 4 of
10 cadaveric kidney recipients. The mean serum
level of creatinine at the time of UTI in cadaveric
and living donor kidney recipients was 5.3 ± 1.65
mg/dL and 2.36 ± 1.95 mg/dL, respectively
(P = .022). The mean dose of mycophenolate
mofetil, prednisolone, and cyclosporine A at that
time were 1516.9 ± 340.4 mg/d, 43.58 ± 12.6
mg/d, and 354.2 ± 109.8 mg/d, respectively.
Five of 10 patients who developed enterococcal
UTI had received ATG previously, which
TABLE 3. Donor type of recipients with posttransplant infectious complications
Living-unrelated (%) Living-related (%) Cadaveric (%)
Urinary tract infections
51 (49.9) 4 (33.3) 4 (40) .82
Respiratory tract infections
5 (4.2) 2 (16.7) 2 (20) .044
22 (18.3) 1 (8.3) 2 (20) .67
6 (5) - 1 (10) .096
29 (24.2) 2 (16.7) 4 (40) .22
7 (5.8) 1 (8.3) 3 (30) .023
TABLE 4. Age distribution of posttransplant infectious complications
Number of kidney
≤ 14 6 (4) 4 (66.7) 1 (16.7) 2 (33.3) -
15 to 29 33 (23) 12 (36.4) 4 (12.1) 5 (15.2) 3 (9.1)
30 to 44 45 (32) 14 (31.1) 10 (22.2) 14 (31.1) 3 (6.7)
45 to 59 45 (32) 20 (44.4) 9 (20.0) 11 (24.4) 3 (6.7)
59 < 13 (9) 9 (69.2) 1 (7.7) 3 (23.1) 2 (15.4)
142 (100) 59 25 35 11
.085 .66 .57 .77
TABLE 5. Major causes of end-stage renal disease in kidney recipients with posttransplant complications and
in dead patients
22 6 4 4 5 2 1
3 - 2 1 - - 1
7 4 3 2 2 1 -
4 4 - - - - -
14 4 3 2 4 2 -
5 2 1 2 - - -
Posttransplant Infectious Complications
indicates a significant association between
ATG administration and enterococcal UTI
(P = .04).
Of all patients with UTI, 13 developed acute
rejection, and graft loss was seen in 2. Five
patients with the episodes of UTI died within 1
year. The mean serum level of creatinine at the
time of acute rejection in patients with and
without a previous urinary infection was 6.73 ±
0.91 mg/dL and 3.98 ± 0.47 mg/dL, respectively
(P = .032). Pyelonephritis, caused by Klebsiella
and Escherichia coli, occurred in 2 patients, the
latter of which was in a diabetic patient.
Viral infections. Cytomegalovirus disease
occurred in 25 patients (18%; 17 men, 8 women),
28% and 16% of whom were hypertensive and
diabetic, respectively. The mean time interval
between transplantation and diagnosis of CMV
disease was 136 ± 116.05 days (range, 14 to 331
days). Nineteen percent of CMV disease cases
were diagnosed during hospitalization. The mean
serum level of creatinine at the time of positive
CMV antigen detection was 2.18 ± 0.95 mg/dL.
The mean dosages of mycophenolate mofetil,
prednisolone, and cyclosporine A at that time
were 1700 ± 240.5 mg/d, 18.9 ± 10.1 mg/d, and
285.4 ± 67.8 mg/d, respectively. Three patients
(12%) had received ATG before infection. Of
patients with CMV disease, 15 had experienced
UTI before (Klebsiella in 9 and Escherichia coli in
3 were the most frequent causative organisms).
Acute rejection with a mean serum creatinine
level of 4.26 ± 2.46 mg/dL was seen later in 8
patients (32%) who had CMV disease. Two of
them (8%) were cadaveric kidney recipients, and
there were 2 kidney recipients from living donors
who both died.
Hepatitis C serologic tests, at the time of
transplantation, revealed the positive HCV
antibody in 3 patients (HCV RNA was negative).
Acute rejection occurred in 2 of them with serum
creatinine levels of 2.6 mg/dL and 6.7 mg/dL at
the time of diagnosis (170 days and 147 days
postoperatively). One patient developed HCV
infection (positive enzyme-linked immunosorbent
assay and polymerase chain reaction results) 534
days after transplantation,
pretransplant serologic tests were negative. There
was a significant association between positive
HCV serologic tests and ATG administration
(P = .049).
At the time of transplantation, 2 patients had a
positive HBs antigen on serologic testing.
Urinary tract infection occurred in both. One
patient with negative
transplantation developed HBV infection 205
days after transplantation.
Two patients developed herpes zoster infection.
The first patient was a 10-year-old boy with a
serum creatinine level of 2 mg/dL, diagnosed 104
days postoperatively. The second was a 29-year-
old man in whom herpes zoster infection was
detected 144 days postoperatively and his serum
creatinine level was 3.2 mg/dL at diagnosis. One
patient developed herpes simplex infection 27
days after transplantation. This patient had a
positive CMV antigen at the same time.
HBV tests at
Wound infection. Wound infection developed
in 7 patients (5%), 4 of whom were diabetic. The
mean time between transplantation and infection
diagnosis was 147 ± 126.08 days (range, 10 to 355
days), and the mean age of the patients was
44 ± 8.33 years. The most common causative
organisms were Escherichia coli (2 cases),
Enterococci (2 cases), and Staphylococcus aureus
(2 cases). There was a significant correlation
between CMV infection and staphylococcal
(aureus and coagulase-negative) wound infection
(P = .041).
Other infections. Respiratory tract infections
were seen in 9 patients (6.3%), of whom 5
developed pneumonia. The causative pathogens
are demonstrated in Table 2. Tuberculosis was
found in 1 patient. Other infections and their
characteristics are shown in Table 6.
Acute rejection. There were 35 patients (25%)
who experienced acute rejection. The mean time
of the rejection was 85.32 ± 116.97 days after
transplantation. The mean age of the patients
was 45 ± 14.5 years, and the mean serum
creatinine level was 4.87 ± 2.87 mg/dL. Of
patients with acute rejection episodes, 40% and
11% were hypertensive and diabetic, respectively.
Moreover, 14 had received ATG before rejection,
4 had received cadaveric kidney allograft, and 3
died. Simultaneous rejection and infection
occurred in 10 patients (7%), and the concurrent
infections were UTI in 5, CMV disease in 2,
sepsis in 2, and HCV infection in 1. At the time
of acute rejection, the mean dosages of
immunosuppressive drugs were as follows:
mycophenolate mofetil, 1647.05 mg/d;
Pourmand et al
prednisolone, 28.6 mg/d; and cyclosporine A,
There were 16 patients (11%) with graft loss
within 1 year (5 due to rejection and 11 due to
death). The mean age and mean time of graft loss
were 43.4 ± 13.45 years and 151.8 ± 194.25 days
after transplantation, respectively. Of these
patients, 2 had developed CMV infection, 2 had
experienced UTI, and 5 had developed sepsis
before graft loss.
Mortality. Overall mortality rate was 7.7%
(11 patients; 7 men and 4 women). Of the
patients who died within the first posttransplant
year, 45% and 18% were hypertensive and
diabetic, respectively. Infection-related mortality
was 3.5% (5 patients), all due to sepsis. Mortality
was associated with Gram-negative Entero-
bacteriaceae (2 patients), Staphylococcus aureus
(1 patients), Staphylococcus coagulase-negative
(1 patient), and Aspergillus (1 patient).
There are some studies with different results on
the overall incidence of the posttransplant
infections and most commonly involved sites.(11-16)
Maraha and colleagues(17)studied 192 patients
between 1992 and 1997. They reported that 71%
of patients developed an infection during the first
year of transplantation, the most frequent of
which were UTI (61%), RTI (8%) and intra-
abdominal infections (7%).
The immunosuppressive regimen and donor
type play important roles in developing
Fishman and Rubin have
reported that the
immunosuppression is a risk factor for
Bacterial infections often occur in the first
month following transplantation, and technical
factors may play an important etiologic
role.(2,4,5,7,21,22)From the second to the sixth
posttransplant month, two thirds of the febrile
illnesses are caused by CMV disease.(2,5,7,23-25)
Cytomegalovirus is generally the most frequent
single cause of infectious complications after
kidney transplantation, but fewer than 20% of
patients actually develop the typical symptoms of
especially Escherichia coli and Klebsiella are the
net state of
TABLE 6. Fungal, protozoal, and other bacterial infections found in the patients of this study
UC: urinary calculi, HTN: hypertension, GN: glomerulonephritis, DM: diabetes mellitus, PCKD: polycystic kidney disease,
CMV: cytomegalovirus, RN: reflux nephropathy, U: living-unrelated, C: cadaveric
96 PCKD C Expired
134 DM U -
Yeast 3 (2)
GN U -
2 (1) 46
Otitis media 2 (1) 59
CMV Ag+ &
Aspergillosis 1 (0.7) 125 Aspergillus fumigatus UC U Expired
Candidiasis 1 (0.7) 172 Candida albicans HTN U CMV Ag+
Osteomyelitis 1 (0.7) 120 Staphylococcus aureus DM & HTN U
Endocarditis 1 (0.7) 282 Enterococci HTN U CMV Ag+
1 (0.7) 45 Klebsiella GN U -
Mycobacteria 1 (0.7)
HTN U -
1 (0.7) 190 Escherichia coli DM U -
Posttransplant Infectious Complications
major pathogens among bacterial infections in
kidney transplant patients.(1,11,17) Mucocutaneous
infections with herpes simplex virus and
varicella-zoster virus occur more often in kidney
transplant patients than they do in the normal
population, most often in the first 6 months after
occurs only in fewer than 5% of kidney allograft
recipients, while the prevalence of positive HCV
antibody in kidney transplant candidates is about
50% in some studies.(22,27)The overall rate of
HCV positive patients in our study was 3%.
The most common fungal infection after
transplantation is candidiasis, which usually
colonizes in mucosa and may cause superficial
mucositis, such as esophagitis or cystitis. The
second common fungal infection is aspergillosis,
especially with Aspergillus fumigatus
Aspergillus flavus species.(2,7,11)
Mycobacterial infection is an important
problem after kidney transplantation in
developing countries and is more prevalent in
transplanted patients than it is in a normal
population. In one series reported from India, the
incidence of mycobacterial infection in kidney
allograft recipients during a median 3 years'
follow-up was 13.3%.(28)Also, a study in China
revealed an incidence rate of 5% over a 2-year
period.(29)Mycobacterial infection is relatively
less prevalent in the kidney recipients in western
countries.(30) We had only 1 patient with
It has been shown that kidney allograft
recipients who develop opportunistic infections
during the first year after transplantation,
usually have higher serum creatinine levels,
receive higher doses of immunosuppressive
drugs, and have more recurrent rejection
episodes.(2,7)Overall incidence of mortality in the
first year after transplantation is 5% to 10%, half
of which is caused
In our study, the most common causative
agents were Klebsiella (34 cases) and CMV (25
cases). Similar to other studies, the most
frequent site of infection was the lower urinary
tract (42%). The average time of detection of
bacterial infections (58 days) and the average
time of CMV development (136 days) were in
agreement with other studies. Our findings
indicated that UTI and CMV had no significant
association with acute rejection. Patients' sex had
no impact on UTI incidence. In contrast with
Hepatitis B infection
HBV infection, incidence of HCV and
mycobacterial infections were less frequent than
those in other studies.(22,27-30)Eleven patients
died during the first year of transplantation, 5 of
whom (45%) had developed an episode of
infection before death, and the mean dosage of
immunosuppressive drugs at the discharge time
was significantly higher for these patients
compared with others. Justification of these
results needs further well-designed studies.
This study identifies infections as the
important cause of morbidity and mortality
during the posttransplant period. Therefore, we
recommend performing serologic tests before and
meticulously follow those who are at risk.
Furthermore, kidney recipients who have a
higher serum creatinine level and receive high
doses of immunosuppressive drugs at the time of
discharge will be considered as high-risk patients
complications and death). These patients must be
evaluated and followed more carefully. Also,
treatment of all infections in recipients before
transplantation is recommended. In case of a
symptomatic infection, empirical treatment
should be initiated before the test results of
collected tissue and body fluid specimens are
As the urinary tract is the most common site
of infection, attention should be paid to the
urinary symptoms of high-risk patients (eg,
diabetics). Also, early removal of urethral
catheter is recommended to reduce the risk of
to recognize and
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