NDT Advance Access originally published online on November 28, 2006
Nephrology Dialysis Transplantation 2007 22(3):972-973; doi:10.1093/ndt/gfl659
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Multiple infections after commercial renal transplantation in India
Email: janez.tomazic{at}kclj.siSir,
The increased demand for transplantable kidneys has not met with a corresponding increase in the supply of these organs. Many patients travel to other, mostly developing countries, in search of commercial transplantation. In order to perform the procedure rapidly, standards of transplantation are compromised [1]. Besides the clinical issues, ethical problems are also of equal concern.
We report the case of a 56-year-old Slovenian male who underwent renal transplantation for undiagnosed chronic renal failure. He refused a suggested haemodialysis and await for transplantation. With no consultation with a nephrologist, he privately arranged the transplantation in India. Live-donor renal transplantation was performed in September 2004, in a New Delhi private clinic. The donor was a 28-year-old male from Bangladesh. The post-operative course was uneventful, and the patient was discharged from the hospital on the day 10. Tacrolimus and methylprednisolone were used for immunosuppression. The patient immediately returned to Slovenia and consulted his nephrologist. His initial renal function and laboratory parameters were within normal ranges.
Three weeks after the transplantation he became febrile; ESBL-producing Escherichia coli was isolated from blood and urine cultures. Despite treatment with imipenem he remained febrile. Aspergillus terreus was isolated from a partially dehiscent post-operative wound, followed by positive serum galactomannan assay. Treatment with voriconasol was initiated. On the day 40, deep venous thrombosis of the right ileofemoral vein developed (the allograft vein was anastomosed to the right external iliac vein). A few days later, Plasmodium falciparum and Plasmodium vivax were found in the peripheral blood smear (Figure 1A). He was treated with intravenous quinine; parasitaemia (initially 4.8%) cleared in 6 days and his condition temporally improved.
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On the day 53, symptoms and signs of infection reappeared and renal function began to deteriorate. On the basis of a computed tomography scan and sequential renal scintigraphy, a urine leak from the lower renal pole was suspected; the allograft was removed and immunosuppression stopped, the patient was placed in the intensive care unit. The clinical suspicion was confirmed, as the lower pole of the kidney was found to be necrotic (Figure 1B). From the necrotic kidney tissue, ESBL-producing E. coli, Mucor spp. (Figure 1C) and Mycobacterium fortuitum were isolated. Furthermore, strongly birefringent crystalline vascular deposits, most probably talc, accompanied by focal proliferative endarteritis were found in the kidney tissue, suggesting intravenous drug addiction in the kidney donor (Figure 1D). Follow-up quantitative Polymerase chain reaction (PCR) for cytomegalovirus (CMV) revealed 65.000 copies/ml. Liposomal amphotericin B, therapy for non-tuberculous mycobacteriosis and ganciclovir were added to the therapeutic regime. The patient's condition did not improve and despite all efforts, he died 102 days after the transplantation.
This case demonstrates an unfortunate combination of bacterial, fungal and parasitic infections (CMV was reactivation) following kidney transplantation from a living unrelated donor in India. To the authors’ knowledge, 43 cases of post-transplant malaria have been reported [2–4]. During his stay in India, our patient remained in New Delhi and was therefore not exposed to malaria-bearing mosquitoes, so the most likely source of malaria was the allograft. It is highly likely that deep mycosis (A. tereus, Mucor spp.) and M. fortuitum were transmitted by the renal allograft as well. Renal mucormycosis, sharing similarities with our case, has previously been reported in a patient actively using intravenous drugs [5].
Over half of all the renal transplant recipients in tropical countries develop a serious infection at some point in the post-transplant period and 20–40% of them succumb to these infections [1,6,7]. A multitude of factors (unhygienic conditions, hot and humid climate, scanty diagnostic techniques, etc.) contribute to this dismal outcome. In commercial transplantations, the primary objective of the medical team is often profit, and not necessarily the well-being of either donors or recipients.
Conflict of interest statement. None declared.
i
1
2an Ferluga34
1Department of Infectious Diseases
Medical Centre Ljubljana
Japljeva 2, 1000 Ljubljana
2Institute of Microbiology
and Immunology, Medical Faculty
University of Ljubljana
Zaloka 4, 1000 Ljubljana
3Institute of Pathology
Medical Faculty
University of Ljubljana
Korytkova 2, 1000 Ljubljana
4Department of Nephrology
Medical Centre Ljubljana
Zaloka 2, 1000 Ljubljana, Slovenia
References
- Sever MS, Kazancioglu R, Yildiz A, et al. (2001) Outcome of living unrelated (commercial) renal transplantation. Kidney Int 60:1477–1483.[CrossRef][Web of Science][Medline]
- Bemelman F, De Blok K, De Vries P, Surachno S, Ten Berge I. (2004) Falciparum malaria transmitted by a thick blood smear negative kidney donor. Scand J Infect Dis 36:769–771.[Web of Science][Medline]
- Chiche L, Lesage A, Duhamel C, et al. (2003) Posttransplant malaria: first case of transmission of Plasmodium falciparum from a white multiorgan donor to four recipients. Transplantation 75:166–168.[CrossRef][Web of Science][Medline]
- Menichetti F, Bindi ML, Tascini C, et al. (2006) Fever, mental impairment, acute anemia, and renal failure in patient undergoing orthotopic liver transplantation: posttransplantation malaria. Liver Transpl 12:674–676.[CrossRef][Web of Science][Medline]
- Levy E and Bia MJ. (1995) Isolated renal mucormycosis: case report and review. J Am Soc Nephrol 5:2014–2019.[Abstract]
- Jha V and Chugh KS. (2002) Posttransplant infections in the tropical countries. Artif Organs 26:770–777.[CrossRef][Web of Science][Medline]
- Tharayil John G, Shankar V, Talaulikar G, et al. (2003) Epidemiology of systemic mycoses among renal-transplant recipients in India. Transplantation 75:1544–1551.[CrossRef][Web of Science][Medline]
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