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Hsin-Yun Sun,
Patricia Munoz,
Julian Torre-Cisneros, Jose M Aguado,
Roberta Lattes,
Miguel Montejo,
Ana Garcia-Reyne,
Emilio Bouza,
Maricela Valerio,
Rosario Lara,
George T John,
Didier Bruno,
Nina Singh
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ABSTRACT: BACKGROUND: Incidence, characteristics, and risk factors for tuberculosis (TB)-associated immune reconstitution inflammatory syndrome (IRS) in solid-organ transplant (SOT) recipients are not known. METHODS: Patients are composed of 64 consecutive SOT recipients with TB followed for 12 months. IRS was defined based on previously proposed criteria. RESULTS: IRS developed in 14% (9/64) of the patients, a median of 47 days after the use of anti-TB therapy. Liver versus other types of organ transplant recipients (adjusted odds ratio [OR], 6.11; 95% confidence interval [CI], 1.08-34.86), prior cytomegalovirus infection (adjusted OR, 5.65; 95% CI, 0.93-34.47), and rifampin use (adjusted OR, 4.56; 95% CI, 0.74-27) were associated with a higher risk of IRS. The presence of more than one factor (liver transplantation, cytomegalovirus infection, and rifampin use) when compared with none of these factors conferred a 19-fold increase in the risk of IRS (P=0.01). Mortality at 1 year after diagnosis was 33.3% in patients with IRS and 17.2% in those without IRS (P=0.31). CONCLUSIONS: IRS was documented in 14% of the SOT recipients with TB. We determined clinically identifiable factors that may be useful in assessing the risk of tuberculosis-associated posttransplantation IRS.
Transplantation 02/2013; · 4.00 Impact Factor
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Rafael San-Juan,
Begoña De Dios,
David Navarro,
Ana García-Reyne,
Carlos Lumbreras,
Dayana Bravo,
Elisa Costa,
Jose Maria Morales,
Amado Andres,
Carlos Jiménez-Romero,
Juan Delgado,
Mario Fernández-Ruiz,
Francisco López-Medrano, Jose M Aguado
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ABSTRACT: BACKGROUND: Epstein-Barr virus (EBV) DNAemia (EBVd) may be a surrogate marker of the net state of immunosuppression after solid organ transplantation (SOT). METHODS: A sample of 81 SOT recipients (53 renal, 21 liver, and 7 cardiac) from our institution (2003-2004) surviving more than 180 days was analyzed. EBVd was monitored in whole blood within the first 6 months using a real-time polymerase chain reaction assay. Using a Cox proportional hazards model, duration and magnitude of EBVd were assessed as potential surrogate markers for the occurrence of late adverse events (>6 months): graft dysfunction, graft loss, death, and immunosuppression-related adverse events (IRAE), defined by the occurrence of solid organ tumor and opportunistic and severe infections. RESULTS: A median of 10 blood samples per patient was screened. A total of 68 (84%) patients had detectable EBVd. Persistent EBVd (>30 days) was found in 40 (49.4%) and high EBVd (>1500 copies/mL) in 35 (43.3%). Multivariate analyses showed that persistent EVBd and high EBVd levels were independently related to the development of IRAE (hazard ratio, 2.95 and 4.32, respectively), whereas no significant associations were observed with late graft dysfunction or graft loss. CONCLUSIONS: Persistent and high levels of EBVd within the first 6 months after SOT are surrogate markers of increased risk of IRAE.
Transplantation 12/2012; · 4.00 Impact Factor
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ABSTRACT: PURPOSE OF REVIEW: The purpose of this review is to describe the new insights of hepatitis C virus (HCV) infection and renal transplantation. RECENT FINDINGS: HCV is its most frequent cause of liver disease after transplantation. In the long run, HCV infection can lead to cirrhosis, hepatocarcinoma and death in some patients. As interferon is generally contraindicated after transplantation, the best way to treat patients is before transplantation. Long-term patient and graft survival rates are lower in HCV-positive patients than in HCV-negative graft recipients. HCV infection is an independent risk factor for death and graft loss. Mortality is higher, mainly as a result of cardiovascular complications, liver disease and infections but is lower than in HCV-positive patients on the transplant waiting list. New-onset diabetes after transplantation (NODAT), and HCV-related glomerulonephritis, together with chronic rejection and notably transplant glomerulopathy can contribute to graft failure. Despite this factor, transplantation is the best option for the HCV-positive patient on dialysis. Renal transplantation with kidneys from donors with positive anti-HCV antibodies into HCV RNA-positive recipients seems to be safe in the long term. SUMMARY: Renal transplantation is the therapy of choice for dialysis patients with HCV infection. To improve the results, a careful follow-up in the outpatient clinic for early detection of HCV-related complications is mandatory.
Current opinion in organ transplantation 10/2012; · 1.22 Impact Factor
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Rafael San-Juan, Jose M. Aguado,
Carlos Lumbreras,
Jesus Fortun,
Oscar Len,
Patricia Munoz,
Miguel Montejo,
Asunción Moreno,
Elisa Cordero,
Marino Blanes,
Antonio Ramos,
Julian Torre-Cisneros,
Francisco López-Medrano,
Jordi Carratala,
Enrique Moreno
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ABSTRACT: The role of selective intestinal decontamination with fluoroquinolones (FQ-SID) in the prevention of early bacterial infections (EBIs) in liver transplant recipients (LTRs) is unknown. We used the online database of the Spanish Network of Infection in Transplantation/Spanish Network for Research in Infectious Diseases, which prospectively analyzed 1010 LTRs from 12 Spanish hospitals from September 2003 to February 2005. We compared the incidence and etiology of EBIs (30 days after transplantation) in 415 LTRs from 4 centers that used FQ-SID (>7 days) and in 595 LTRs from 8 hospitals that did not use FQ-SID. A multivariate logistic regression analysis (including an adjustment for the transplant center factor) was performed to evaluate the potential protective factor of FQ-SID in the development of EBIs. We reported 266 EBI episodes in 252 LTRs (incidence = 24.9%). There were no differences in the incidence of EBIs between patients in the FQ-SID group and patients not in the FQ-SID group [109/415 (26.3%) versus 143/595 (24%), P = 0.9]. Although LTRs who received FQ-SID had a lower incidence of infections due to enteric bacteria (2.7% versus 6.5%, P = 0.007) and a higher incidence of infections due to nonfermenting gram-negative bacilli (6.6% versus 2.6%, P = 0.004), these findings could not be confirmed after an adjustment by the center factor in the multivariate models. We found no significant differences in the incidence of enterococcal infections (3.4% with FQ-SID versus 3.9% without FQ-SID, P = 0.5). Multivariate analysis did not confirm any protective effect of FQ-SID against the development of EBIs by enteric bacteria. In conclusion, FQ-SID does not reduce the incidence of EBIs in LTRs and could be withheld from this group of patients. Liver Transpl 17:896–904, 2011. © 2011 AASLD.
Liver Transplantation 07/2011; 17(8):896 - 904. · 3.39 Impact Factor
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Rafael San-Juan, Jose M Aguado,
Carlos Lumbreras,
Jesus Fortun,
Oscar Len,
Patricia Muñoz,
Miguel Montejo,
Asuncion Moreno,
Elisa Cordero,
Marino Blanes,
Antonio Ramos,
Julian de la Torre-Cisneros,
Francisco Lopez-Medrano,
Jordi Carratala,
Enrique Moreno
[show abstract]
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ABSTRACT: Although antifungal prophylaxis in high-risk liver transplant recipients (LTR) seems to be clearly justified, the efficacy of universal prophylaxis (UP) including low-risk patients is controversial.
From the study cohort RESITRA-REIPI, which prospectively analyzed 1010 LTR (September 2003 to February 2005) in 12 Spanish hospitals, we compared the incidence of early invasive fungal infection (IFI, first 90 days) between centers performing or not UP with fluconazole (for a minimum of 7 days) in low-risk LTR (none of the following: posttransplant renal failure, urgent transplant/retransplant, or choledochojejunostomy).
Three of 12 centers used UP. A total of 799 LTR were considered as low-risk patients (206 included in the UP group and 593 did not). We reported a total of 11 episodes of early IFI (six due to Candida albicans, one due to C. guillermondii, and three due to Aspergillus fumigatus) in 10 patients (incidence: 1.2%), with two cases of death attributable to IFI (18%) in both patients with invasive aspergillosis. There were no differences in the incidence of IFI between the patients receiving or not UP (4/206:1.9% vs. 6/593:1%, respectively; P=0.36).
IFI is infrequent in LTR not fulfilling major high-risk factors criteria, and prophylaxis with fluconazole in this low-risk group does not seem to be justified.
Transplantation 06/2011; 92(3):346-50. · 4.00 Impact Factor
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ABSTRACT: Rhino-orbital-cerebral disease is a significant manifestation of zygomycosis in solid organ transplant (SOT) recipients. However, its characteristics and outcome are not well addressed.
SOT recipients with zygomycosis as per the European Organization for Research and Treatment in Cancer and the Mycoses Study Group criteria in a cohort study at our centers published previously and those identified with a PubMed search from the 1950s to November 2009 were studied. Patients with mycosis involving the sinuses, orbits, or central nervous system (CNS) were included.
Patients comprised a total of 90 SOT recipients with rhino-orbital-cerebral zygomycosis, including 13 in our cohort and 77 in the literature. CNS disease occurred in 57% (51 of 90). Overall mortality was 52.3% (46 of 88), and the mortality in patients with CNS disease was 73.5% (36 of 49). In logistic regression analysis, older age (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.04-1.21, P=0.002) was associated with a higher mortality rate, whereas lipid formulations of amphotericin B compared with amphotericin B deoxycholate (OR 0.09, 95% CI 0.02-0.50, P=0.006) and surgery (OR 0.12, 95% CI 0.01-0.94, P=0.043) were independently associated with an improved survival even when controlled for CNS involvement and the era of diagnosis of disease.
Rhino-orbital-cerebral zygomycosis, particularly CNS disease, is associated with substantial mortality rate in SOT recipients. Older age is a significant risk factor for mortality, whereas lipid formulations of amphotericin B and surgery improved outcomes.
Transplantation 07/2010; 90(1):85-92. · 4.00 Impact Factor
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Nina Singh, Jose M Aguado,
Hugo Bonatti,
Graeme Forrest,
Krishan L Gupta,
Nasia Safdar,
George T John,
Kenneth J Pursell,
Patricia Muñoz,
Robin Patel, [......],
Nina Clark,
Emily Blumberg,
Marino Blanes Julia,
Abhi Humar,
Sally Houston,
Cornelia Lass-Flörl,
Leonard Johnson,
Erik R Dubberke,
Michelle A Barron,
Olivier Lortholary
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ABSTRACT: Clinical characteristics, risks, and outcomes in solid organ transplant (SOT) recipients with zygomycosis in the era of modern immunosuppressive and newer antifungal agent use have not been defined.
In a matched case-controlled study, SOT recipients with zygomycosis were prospectively studied. The primary outcome measure was success (complete or partial response) at 90 days.
Renal failure (odds ratio [OR], 3.17; P = .010), diabetes mellitus (OR, 8.11; P < .001), and prior voriconazole and/or caspofungin use (OR, 4.41; P = .033) were associated with a higher risk of zygomycosis, whereas tacrolimus (OR, 0.23; P = .002) was associated with a lower risk of zygomycosis. Liver transplant recipients were more likely to have disseminated disease (OR, 5.48; P = .021) and developed zygomycosis earlier after transplantation than did other SOT recipients (median, 0.8 vs 5.7 months; P < .001). Overall the treatment success rate was 60%. Renal failure (OR, 11.3; P = .023) and disseminated disease (OR, 14.6; P = .027) were independently predictive of treatment failure, whereas surgical resection was associated with treatment success (OR, 33.3; P = .003). The success rate with liposomal amphotericin B was 4-fold higher even when controlling for the aforementioned variables.
The risks identified for zygomycosis and for disseminated disease, including those that were previously unrecognized, have implications for further elucidating the biologic basis and for optimizing outcomes in SOT recipients with zygomycosis.
The Journal of Infectious Diseases 09/2009; 200(6):1002-11. · 6.41 Impact Factor
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ABSTRACT: Surgical site infections are common bacterial infections in orthotopic liver transplantation. The purpose of this study was to determine the incidence, timing, location, and risk factors, specifically antibiotic prophylaxis, for surgical site infections. A prospective study was performed that included a population of 1222 consecutive patients (73.0% males) who underwent liver transplantation in Spanish hospitals belonging to the Red de Estudio de la Infección en el Trasplante research network. One hundred seven patients developed surgical site infections. The predominant infection sites were incisional wound (53 episodes) and peritonitis (40 episodes). The timing of the organ/space surgical site infections was slightly delayed in comparison with incisional surgical site infections. Enterococcus spp., Escherichia coli, Staphylococcus aureus, and Acinetobacter baumannii were the predominant pathogens. Choledochojejunal or hepaticojejunal reconstruction (odds ratio, 4.2; 95% confidence interval, 1.6-10.7), previous liver or kidney transplant (odds ratio, 2.6; 95% confidence interval, 1.1-6.3), and more than 4 red blood cell units transfused (odds ratio, 2.0; 95% confidence interval, 1.1-3.4) were independently associated with the development of surgical site infections. Biliary reconstruction by choledochojejunostomy or hepaticojejunostomy increases the risk of surgical site infections.
Liver Transplantation 07/2008; 14(6):799-805. · 3.39 Impact Factor
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Transplantation 07/2008; 85(12):1715-6. · 4.00 Impact Factor
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ABSTRACT: There is limited information about clinical consequences of respiratory virus infections (RVI) in solid organ transplant recipients. No prospective epidemiological study has been published previously.
We selected a cohort of 152 transplant recipients (cardiac, hepatic and renal transplant recipients). Median time from transplantation was 17 months (range 1-50). They were prospectively followed-up for RVI during 7 months (October to April). Clinical and microbiological evaluation (cell culture, shell vial and polymerase chain reaction technique) of each RVI episode was made.
We detected 81 RVI (0.91 episodes/patient/year). Complications were detected in 15/81 episodes (18.5%): acute bronchitis (10 cases), pneumonia (three cases; 3.7% of RVI episodes) and bacterial sinusitis (2 cases). In 4 of 81 episodes (5%), patients needed hospitalization. A respiratory virus was isolated in 17 of 68 nasopharyngeal samples (six respiratory syncytial virus, six influenza, four picornavirus, one adenovirus). Fever presented an 83% positive predictive value for the diagnosis of influenza virus infection among those with a positive microbiological isolation. There were no episodes of acute rejection coincidentally with RVI. Only 54% of the subjects had been previously vaccinated against influenza.
Incidence of RVI among solid organ transplant recipients is similar to general population but complications are higher. A relationship between RVI and rejection was not detected. The rate of influenza vaccination was lower than expected. The presence of fever in a transplant recipient with RVI strongly suggests influenza infection.
Transplantation 11/2007; 84(7):851-6. · 4.00 Impact Factor
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Rafael San Juan Garrido, Jose M Aguado,
Carmen Díaz-Pedroche,
Oscar Len,
Miguel Montejo,
Asuncion Moreno,
Mercedes Gurguí,
Julian Torre-Cisneros,
Felipe Pareja,
Javier Segovia,
Milagros Garcia,
Carlos Lumbreras
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ABSTRACT: The risk of opportunistic infection (OI) is considered to be maximum during the first six months after solid organ transplantation. The aim of this study was to know the incidence and risk factors for OI in the late period (>6 months) compared with the early period (<6 months) after solid organ transplantation.
We used the online database of the Spanish Network of Infection in Transplantation (RESITRA), which prospectively analyzed 2,702 solid organ transplantation recipients from August 2003 to February 2005. Univariate and multivariate analyses were performed to calculate the risk factors associated with the development of late OI.
A total of 131 patients (6%) developed 176 infectious episodes in the late period. Although the incidence of infection and cytomegalovirus disease (0.4 per 1000 transplant days and 0.05 per 1000 transplant days, respectively) was lower than in the early period (3.5 per 1000 transplant days and 0.8 per 1000 transplant days; P<0.0001), the incidence of other OIs was similar in both periods (0.05 per 1000 transplant days versus 0.03 per 1000 transplant-days, P=0.5). Patients with the higher risk for developing late OI were those receiving early cytomegalovirus prophylaxis, patients who developed two or more episodes of acute rejection during the early period, patients with recurrent bacterial infection during the early period, patients with renal failure requiring dialysis, and patients with chronic graft malfunction.
Our data suggest that in some high-risk patients, the critical period of risk for OI must be expanded beyond the first six months after transplant.
Transplantation 01/2007; 82(11):1457-62. · 4.00 Impact Factor
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Nina Singh,
Ajit P Limaye,
Graeme Forrest,
Nasia Safdar,
Patricia Muñoz,
Kenneth Pursell,
Sally Houston,
Fernando Rosso,
Jose G Montoya,
Pamela R Patton,
Ramon Del Busto, Jose M Aguado,
Marilyn M Wagener,
Shahid Husain
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ABSTRACT: We assessed predictive factors and characteristics of patients with late-onset invasive aspergillosis in the current era of novel immunosuppressive agents. Forty transplant recipients with invasive aspergillosis were included in this prospective, observational study initiated in 2003 at our institutions. In 50% (20/40) of these patients, the infections were late-occurring. Receipt of sirolimus in conjunction with tacrolimus for refractory rejection or cardiac allograft vasculopathy (P=0.047) was significantly associated with late-onset infection. The use of depleting or non-depleting T or B-cell antibodies, either as induction or as antirejection therapy did not correlate with time to onset of invasive aspergillosis. Mortality at 90 days was 20% (4/20) for the patients with early-onset infection and 45% (9/20) for those with late-onset infection (P=0.17). Thus, nearly one-half of the Aspergillus infections in transplant recipients in the current era are late-occurring. These data have implications relevant for prophylactic strategies and guiding clinical management of transplant recipients presenting with pulmonary infiltrates.
Medical Mycology 09/2006; 44(5):445-9. · 2.46 Impact Factor
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Nina Singh,
Ajit P Limaye,
Graeme Forrest,
Nasia Safdar,
Patricia Muñoz,
Kenneth Pursell,
Sally Houston,
Fernando Rosso,
Jose G Montoya,
Pamela Patton,
Ramon Del Busto, Jose M Aguado,
Robert A Fisher,
Goran B Klintmalm,
Rachel Miller,
Marilyn M Wagener,
Russell E Lewis,
Dimitrios P Kontoyiannis,
Shahid Husain
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ABSTRACT: : The efficacy of the combination of voriconazole and caspofungin when used as primary therapy for invasive aspergillosis in organ transplant recipients has not been defined.
: Transplant recipients who received voriconazole and caspofungin (n=40) as primary therapy for invasive aspergillosis (proven or probable) in a prospective multicenter study between 2003 and 2005 were compared to a control group comprising a cohort of consecutive transplant recipients between 1999 and 2002 who had received a lipid formulation of AmB as primary therapy (n=47). In vitro antifungal testing of Aspergillus isolates to combination therapy was correlated with clinical outcome.
: Survival at 90 days was 67.5% (27/40) in the cases, and 51% (24/47) in the control group (HR 0.58, 95% CI, 0.30-1.14, P=0.117). However, in transplant recipients with renal failure (adjusted HR 0.32, 95% CI: 0.12-0.85, P=0.022), and in those with A. fumigatus infection (adjusted HR 0.37, 95% CI: 0.16-0.84, P=0.019), combination therapy was independently associated with an improved 90-day survival in multivariate analysis. No correlation was found between in vitro antifungal interactions of the Aspergillus isolates to the combination of voriconazole and caspofungin and clinical outcome.
: Combination of voriconazole and caspofungin might be considered preferable therapy for subsets of organ transplant recipients with invasive aspergillosis, such as those with renal failure or A. fumigatus infection.
Transplantation 03/2006; 81(3):320-6. · 4.00 Impact Factor
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Esteban Martínez,
Jose M Miró,
Benito Almirante, Jose M Aguado,
Pedro Fernandez-Viladrich,
Manuel L Fernandez-Guerrero,
Jose L Villanueva,
Fernando Dronda,
Alfonso Moreno-Torrico,
Miguel Montejo,
Pedro Llinares,
Jose M Gatell
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ABSTRACT: We performed a clinical study of pneumococcal endocarditis (PE) in adults at 15 major Spanish hospitals during a 21-year period (1978-1998). During this time, 63 patients had PE due to Streptococcus pneumoniae diagnosed. Of the 63 isolates recovered from these patients, 24 (38%) and 6 (10%) showed resistance to penicillin (minimum inhibitory concentration [MIC], 0.1-4 microg/mL) and cefotaxime (MIC, 1 microg/mL), respectively. Twenty-two (35%) of the patients died. Left-side heart failure, but not penicillin resistance, was independently associated with a higher risk of death (odds ratio, 1.33; 95% confidence interval, 1.04-1.71; P=.026). Patients without meningitis who had PE due to penicillin-resistant S. pneumoniae could be treated with high-dose penicillin or a third-generation cephalosporin if the MIC for penicillin was < or =1 microg/mL. For patients with concurrent meningitis, high doses of cefotaxime could be used if the MIC for cefotaxime was < or =1 microg/mL. Early recognition of heart failure and surgery may help to decrease mortality.
Clinical Infectious Diseases 08/2002; 35(2):130-9. · 9.15 Impact Factor
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Jose M. Aguado,
Jose A. Herrero,
Joan Gavaldá,
Julian Torre-Cisneros,
Marino Blanes,
Gabriel Rufí,
Asunción Moreno,
Mercé Gurguí,
Marcelino Hayek,
Carlos Lumbreras,
the Spanish Transplantation Infection Study Group
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ABSTRACT: Background. Tuberculosis is unusual in transplant recipients. The incidence, clinical manifestations, and optimal treatment of this disease in this population has not been adequately defined. The present study was undertaken to assess the incidence, clinical features, and response to therapy of Mycobacterium tuberculosis infection in solid-organ transplant recipients.
Methods. We evaluated retrospectively the incidence, clinical characteristics, diagnostic procedures, antituberculous treatment, clinical course, and factors influencing mortality in 51 solid-organ transplant recipients who developed tuberculosis after transplantation. We also reviewed the world literature on tuberculosis in solid-organ transplantation.
Results. The overall incidence of tuberculosis was 0.8%. The localization was pulmonary in 63% of the cases, disseminated in 25%, and extrapulmonary in 12%. Tuberculosis developed from 15 days to 13 years after surgery (mean, 23 months). In one third of the cases, diagnosis was not suspected initially, and in three cases, diagnosis was made at necropsy. Fever was the most frequent symptom, followed by constitutional symptoms, cough, respiratory insufficiency, and pleuritic pain. Fifteen patients (33%) developed hepatotoxicity during treatment; hepatotoxicity was severe in seven cases. Hepatotoxicity was higher in patients receiving four or more antituberculous drugs (50%) than in patients receiving three drugs (21%; P=0.03). Serum levels of cyclosporine decreased in the 26 patients under the simultaneous use of rifampin. Nine of them (35%) developed acute rejection, and five (56%) died, in comparison with 3 of 17 patients (18%) who did not develop rejection after the use of cyclosporine and rifampin (P=0.03). Although microbiological response was favorable in 94% of the 35 patients who completed 6 or more months of treatment, 16 other patients (31%) died before diagnosis or in the course of treatment. None of the patients treated for more than 9 months died as a consequence of tuberculosis, whereas the mortality rate was 33% among those treated for 6 to 9 months (P=0.03). Use of antilymphocyte antibodies or high doses of steroids for acute rejection before tuberculosis was associated with a higher mortality rate.
Conclusions. M tuberculosis causes serious and potentially life-threatening disease in solid-organ transplant recipients. Treatment with at least three drugs during 9 months or more, avoiding the use of rifampin, appears to be appropriate.
Transplantation 05/1997; 63(9):1278-1286. · 4.00 Impact Factor
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ABSTRACT: We evaluated the pathogenic role of Corynebacterium urealyticum in the development of encrusted pyelitis (EP) and encrusted cystitis (EC), and their clinical consequences in renal transplant recipients. During a 4-year period, we studied seven renal transplant recipients with EP and two with EC. The records of 320 other renal transplant patients studied during the same period were used as a control group. C urealyticum (> or = 10(5) CFU/ml) was isolated from 4 patients with EP (urine 3, blood 1) and from 1 patient with EC (urine). Alkaline urines with struvite crystals, microscopic hematuria, and sterile conventional urine cultures were present in all our cases. All the patients with EP developed obstructive uropathy with deterioration of the renal function and pyelonephritis (4 patients) or renal abscesses (3 patients). Chronic urinary discomfort and macroscopic hematuria were present in the 2 patients with EC. Long-term vesical and ureteral catheterization were considered the most important risk factors for the development of EC and EP, respectively. Vancomycin was successfully used in 5 cases, but all the patients required a derivative procedure or a surgical resection of the incrustations to improve. We conclude that EP and EC should be investigated in renal transplant patients who develop pyelonephritis, obstructive uropathy, or chronic urinary symptoms. EP and EC could lead to the loss of their grafts. C urealyticum appears to have a pathogenic role in these entities.
Transplantation 08/1993; 56(3):617-622. · 4.00 Impact Factor
