ABSTRACT
The Scientific Registry of Transplant Recipients (SRTR) serves to collect data on organ transplants performed in the United States. Although the infectious diseases data are limited and include mostly pretransplant serologies and other nonspecific infection-related outcomes, this multicenter data collection allows for insightful national data and the ability to monitor trends over time. We reviewed the published concise reports for each organ type in SRTR reports containing data from 2005 to 2014, and summarized our findings with respect to cytomegalovirus (CMV), Epstein-Barr virus, posttransplant lymphoproliferative disorder (PTLD), hepatitis B virus (HBV), hepatitis C virus (HCV), HIV, general infection, and prophylaxis. Our review highlights a few developments. While rates of donor-recipient CMV serology combinations remain fairly constant over time, there are generally more seronegative donors and recipients among living donor transplants. There has been a reduction in PTLD for pediatric transplant recipients. There has also been a slight reduction in anti-HBV core antibody-positive donor organs and stable reporting of HCV-positive donor organs and HIV-positive recipients.
Subject(s)
Communicable Diseases/etiology , Organ Transplantation/adverse effects , Registries/ethics , Transplant Recipients , Humans , Risk FactorsABSTRACT
BACKGROUND: Spontaneous bacterial peritonitis (SBP) carries appreciable morbidity and mortality in the pre-liver transplant (LT) setting. However, the occurrence of SBP and its consequences in the post-LT setting have not been well characterized. METHODS: This is a retrospective study of SBP occurring in post-LT patients between January 2007 and December 2012. Outcomes were compared to a cohort of post-LT patients with allograft failure and ascites without SBP. RESULTS: The most common indication for liver transplantation in this cohort was hepatitis C. A total of 29 episodes of SBP in 21 patients were identified. Escherichia coli (19%) and Klebsiella pneumoniae (10%) were the most frequent pathogens identified. Six patients died during their first episode of SBP. Ten patients were eventually listed for liver re-transplantation (re-LT) after their first episode of SBP; 5 of these patients were transplanted and the other 5 died. Of the 5 who were transplanted, 2 died shortly after re-transplant, and 3 are still alive. The cause of death in the majority of patients was infection (83.3%). The median time from onset of ascites to death was 214 days (range: 10-1085 days) and from the first episode of SBP to death was 50.5 days (range: 4-549 days). In contrast, the median time from onset of ascites to death in patients with allograft failure and ascites without SBP was 331.5 days (45-2400 days). CONCLUSIONS: Allograft failure with ascites is a poor prognostic factor and these patients should be considered high risk for re-LT. SBP may accelerate the time to mortality.
Subject(s)
Bacterial Infections/mortality , Graft Rejection/epidemiology , Hepatitis C, Chronic/surgery , Liver Cirrhosis/complications , Liver Transplantation/adverse effects , Peritonitis/mortality , Adolescent , Adult , Aged , Ascites/etiology , Bacterial Infections/microbiology , Escherichia coli/isolation & purification , Female , Graft Rejection/virology , Humans , Klebsiella pneumoniae/isolation & purification , Liver Cirrhosis/surgery , Male , Middle Aged , Peritonitis/microbiology , Prognosis , Retrospective Studies , Risk Factors , Time Factors , Transplantation, Homologous/adverse effects , Young AdultABSTRACT
We report an HIV-positive renal transplant recipient with delayed graft function who was converted from tacrolimus to belatacept in an attempt to improve renal function. The patient had kidney biopsies at 4 and 8 weeks posttransplant that revealed acute tubular necrosis and mild fibrosis. After 14 weeks of delayed function, belatacept was initiated and tacrolimus was weaned off. Shortly after discontinuing tacrolimus, renal function began to improve. The patient was able to discontinue dialysis 21 weeks posttransplant. HIV viral load was undetectable at last follow-up. To our knowledge, this is the first report of belatacept use in a patient with HIV.
Subject(s)
Abatacept/therapeutic use , Delayed Graft Function/drug therapy , Graft Rejection/prevention & control , HIV Infections/complications , Kidney Failure, Chronic/surgery , Kidney Transplantation , Glomerular Filtration Rate , Graft Survival , HIV Infections/virology , HIV-1/isolation & purification , Humans , Immunosuppressive Agents/therapeutic use , Kidney Failure, Chronic/epidemiology , Kidney Function Tests , Male , Middle Aged , Prognosis , Risk Factors , Transplant RecipientsABSTRACT
BACKGROUND: Liver transplantation (LT) is a treatment option for select human immunodeficiency virus (HIV)-infected patients with advanced liver disease. The aim of this study was to describe LT evaluation outcomes in HIV-infected patients. METHODS: All HIV-infected patients referred for their first LT evaluation at the Mount Sinai Medical Center were included in this retrospective, descriptive cohort study. Multivariable logistic regression was used to identify factors independently associated with listing. RESULTS: Between February 2000 and April 2012, 366 patients were evaluated for LT, with 66 (18.0%) listed for LT and 300 (82.0%) not listed. Fifty-one patients (13.9%) died before completing evaluation and 85 (23.2%) were too early for listing. Reasons patients were declined for listing were psychosocial (15.8%), HIV-related (10.4%), loss to follow-up (9.6%), surgical/medical (6.0%), liver-related (4.4%), patient choice (3.4%), and financial (1.6%). Listed patients were more likely to have hepatocellular carcinoma (HCC) (43.1% vs. 17.1%; P < 0.0001) and less likely to have hepatitis B (6.2% vs. 15.7%; P = 0.04) or a psychiatric history (19.7% vs. 35.2%; P = 0.02) than those not listed. In multivariable analysis, HCC (odds ratio [OR] 5.79; 95% confidence interval [95% CI]: 2.97-11.28), model for end-stage liver disease (MELD) score at referral (OR 1.06; 95% CI 1.01-1.11), and hepatitis B (OR 0.26; 95% CI 0.08-0.79) were associated with listing. CONCLUSION: MELD score and HCC were positive predictors of listing in HIV-infected patients referred for LT evaluation and, therefore, timely referrals are vital in these patients. As MELD is a predictor for death while undergoing evaluation, rapid evaluation should be performed in HIV-infected patients with a higher MELD score.
Subject(s)
End Stage Liver Disease/surgery , HIV Infections/complications , Liver Transplantation , Patient Selection , Waiting Lists , Adult , Aged , End Stage Liver Disease/complications , End Stage Liver Disease/diagnosis , End Stage Liver Disease/mortality , Female , HIV Infections/mortality , Humans , Logistic Models , Male , Middle Aged , Multivariate Analysis , Referral and Consultation , Retrospective Studies , Severity of Illness Index , Waiting Lists/mortalityABSTRACT
Use of organs from donors testing positive for hepatitis B virus (HBV) may safely expand the donor pool. The American Society of Transplantation convened a multidisciplinary expert panel that reviewed the existing literature and developed consensus recommendations for recipient management following the use of organs from HBV positive donors. Transmission risk is highest with liver donors and significantly lower with non-liver (kidney and thoracic) donors. Antiviral prophylaxis significantly reduces the rate of transmission to liver recipients from isolated HBV core antibody positive (anti-HBc+) donors. Organs from anti-HBc+ donors should be considered for all adult transplant candidates after an individualized assessment of the risks and benefits and appropriate patient consent. Indefinite antiviral prophylaxis is recommended in liver recipients with no immunity or vaccine immunity but not in liver recipients with natural immunity. Antiviral prophylaxis may be considered for up to 1 year in susceptible non-liver recipients but is not recommended in immune non-liver recipients. Although no longer the treatment of choice in patients with chronic HBV, lamivudine remains the most cost-effective choice for prophylaxis in this setting. Hepatitis B immunoglobulin is not recommended.
Subject(s)
Hepatitis B virus/immunology , Hepatitis B/prevention & control , Liver Transplantation/methods , Tissue Donors , Antiviral Agents/chemistry , Antiviral Agents/therapeutic use , Cost-Benefit Analysis , Heart Transplantation/methods , Hepatitis B/virology , Hepatitis B Antibodies/immunology , Hepatitis B Core Antigens/immunology , Humans , Kidney Transplantation/methods , Lamivudine/therapeutic use , Societies, Medical , Tissue and Organ Procurement , United StatesABSTRACT
Infection with Strongyloides stercoralis is typically asymptomatic in immunocompetent hosts, despite chronic infection. In contrast, immunocompromised hosts such as solid organ transplant recipients are at risk for hyperinfection syndrome and/or disseminated disease, frequently resulting in fatal outcomes. Infection in these recipients may result from reactivation of latent infection or infection through transmission from an infected donor. We describe the Centers for Disease Control and Prevention's experience with seven clusters of donor-derived infection from 2009 to 2013. Six of the seven (86%) donors were born in Latin America; donor screening was not performed prior to organ transplantation in any of these investigations. Eleven of the 20 (55%) organ recipients were symptomatic, two of whom died from complications of strongyloidiasis. We also describe the New York Organ Donor Network (NYODN) experience with targeted donor screening from 2010 to 2013. Of the 233 consented potential donors tested, 10 tested positive for Strongyloides antibody; and 18 organs were transplanted. The majority (86%) of the donors were born in Central or South America. Fourteen recipients received prophylaxis after transplantation; no recipients developed strongyloidiasis. The NYODN experience provides evidence that when targeted donor screening is performed prior to transplantation, donor-derived infection can be averted in recipients.
Subject(s)
Donor Selection/methods , Strongyloides stercoralis , Strongyloidiasis/complications , Transplantation , Adult , Aged , Animals , Centers for Disease Control and Prevention, U.S. , Female , Humans , Immunocompromised Host , Kidney Transplantation/adverse effects , Latin America , Liver Transplantation/adverse effects , Male , Middle Aged , Postoperative Complications , Strongyloidiasis/epidemiology , Tissue Donors , Transplant Recipients , United StatesABSTRACT
Donor-derived bacterial infection is a recognized complication of solid organ transplantation (SOT). The present report describes the clinical details and successful outcome in a liver transplant recipient despite transmission of methicillin-resistant Staphylococcus aureus (MRSA) from a deceased donor with MRSA endocarditis and bacteremia. We further describe whole genome sequencing (WGS) and complete de novo assembly of the donor and recipient MRSA isolate genomes, which confirms that both isolates are genetically 100% identical. We propose that similar application of WGS techniques to future investigations of donor bacterial transmission would strengthen the definition of proven bacterial transmission in SOT, particularly in the presence of highly clonal bacteria such as MRSA. WGS will further improve our understanding of the epidemiology of bacterial transmission in SOT and the risk of adverse patient outcomes when it occurs.
Subject(s)
Genome, Bacterial , Liver Transplantation/adverse effects , Methicillin-Resistant Staphylococcus aureus/isolation & purification , Staphylococcal Infections/transmission , Tissue Donors , Adult , Cadaver , DNA, Bacterial/genetics , Female , Humans , Methicillin-Resistant Staphylococcus aureus/genetics , Sequence Analysis, DNA , Staphylococcal Infections/microbiologyABSTRACT
Candida osteomyelitis is associated with significant morbidity; however, data on the management of Candida osteomyelitis are limited. The Prospective Antifungal Therapy (PATH) Alliance® registry is a comprehensive, multicenter, prospective, observational registry that collected data on patients with invasive fungal infections between 2004 and 2008. The aim of this descriptive analysis was to evaluate the clinical characteristics, treatment, and outcomes of patients with Candida osteomyelitis. Using the PATH Alliance® registry, we performed a review of all patients with a proven diagnosis of Candida osteomyelitis who received a minimum of 14 days of antifungal treatment and/or a therapeutic surgical intervention (n = 53). The epidemiology, diagnosis, treatment, and outcomes of these patients were assessed at 12 weeks. C. albicans (56.6 %) was the most commonly identified organism, followed by C. parapsilosis (18.9 %), C. glabrata (9.4 %), and C. tropicalis (9.4 %). The mean treatment duration was 54.9 days. Multiple different treatment regimens were administered to patients. These included fluconazole (56.0 %), echinocandins (29.3 %), amphotericin B formulations (10.7 %), and voriconazole (4.0 %). Twenty-eight patients (52.8 %) also had a therapeutic surgical intervention. Clinical response was improved in 38 (71.7 %) patients (43.4 % complete and 28.3 % partial response), stable in 11 (20.8 %), and worse in one (1.9 %); three (5.7 %) patients had unknown response. The 12-week survival rate was 93.8 %. In summary, C. albicans was the predominant pathogen, and fluconazole was the most commonly administered agent. However, treatment patterns vary and remain non-standardized. Concurrent candidemia was infrequent, and 12-week survival was notably good in this series of 53 patients with Candida osteomyelitis.
Subject(s)
Antifungal Agents/therapeutic use , Candida/isolation & purification , Candidiasis/drug therapy , Candidiasis/microbiology , Osteomyelitis/drug therapy , Osteomyelitis/microbiology , Adolescent , Adult , Candida/classification , Candidiasis/epidemiology , Candidiasis/pathology , Child , Debridement , Female , Humans , Male , Middle Aged , Osteomyelitis/epidemiology , Osteomyelitis/pathology , Prospective Studies , Registries , Treatment Outcome , Young AdultABSTRACT
Invasive aspergillosis (IA) contributes significantly to the burden of infectious complications in heavily immunosuppressed patients with acute leukemia. The infection is typically acquired via inhalation into the respiratory tract, and the lungs are most commonly involved. However, disseminated disease may occur and reports of isolated extrapulmonary infection suggest the gastrointestinal tract is likely an additional portal of entry for this organism. We describe a case of primary hepatic aspergillosis in a patient with acute myelogenous leukemia. The patient did not respond to medical therapy with antifungals and ultimately required surgical exploration and drainage. IA should be considered in an immunosuppressed patient with hepatic abscesses and may require a combined surgical and medical approach to therapy.
Subject(s)
Antifungal Agents/therapeutic use , Aspergillosis/complications , Induction Chemotherapy/adverse effects , Leukemia, Myeloid, Acute/complications , Liver Abscess/microbiology , Stem Cell Transplantation/adverse effects , Aspergillosis/diagnosis , Aspergillosis/drug therapy , Aspergillosis/surgery , Drainage , Fatal Outcome , Humans , Hyphae/classification , Immunocompromised Host , Leukemia, Myeloid, Acute/drug therapy , Leukemia, Myeloid, Acute/surgery , Liver/microbiology , Liver/pathology , Liver Abscess/drug therapy , Liver Abscess/surgery , Male , Middle AgedABSTRACT
Vancomycin-intermediate Staphylococcus aureus (VISA) infections are an emerging problem and antibiotic options are limited. We report the first case, to our knowledge, of heteroresistant VISA mediastinitis and bacteremia in a patient with a ventricular assist device who underwent orthotopic heart transplantation with clinical cure.
Subject(s)
Anti-Bacterial Agents/pharmacology , Bacteremia/drug therapy , Heart Transplantation , Mediastinitis/drug therapy , Staphylococcal Infections/drug therapy , Staphylococcus aureus/drug effects , Adult , Aminoglycosides/pharmacology , Aminoglycosides/therapeutic use , Anti-Bacterial Agents/therapeutic use , Bacteremia/microbiology , Bacteremia/surgery , Debridement , Defibrillators, Implantable , Female , Heart-Assist Devices/adverse effects , Heart-Assist Devices/microbiology , Humans , Lipoglycopeptides , Mediastinitis/microbiology , Mediastinitis/surgery , Staphylococcal Infections/microbiology , Staphylococcal Infections/surgery , Staphylococcus aureus/isolation & purification , Treatment Outcome , Vancomycin/pharmacology , Vancomycin/therapeutic use , Vancomycin ResistanceABSTRACT
Cryptosporidium rarely affects the lungs, and is not typically associated with the immune reconstitution inflammatory syndrome (IRIS). We describe the first published case of pulmonary IRIS following the initiation of antiretroviral therapy in a patient with AIDS and pulmonary cryptosporidiosis, and discuss its implications for HIV patient care.
Subject(s)
AIDS-Related Opportunistic Infections/drug therapy , Anti-HIV Agents/adverse effects , Cryptosporidiosis/diagnosis , HIV Infections/drug therapy , Immune Reconstitution Inflammatory Syndrome/etiology , AIDS-Related Opportunistic Infections/complications , CD4 Lymphocyte Count , Cryptosporidiosis/complications , Cryptosporidium/isolation & purification , Diarrhea/etiology , HIV Infections/complications , HIV Infections/immunology , Humans , Male , Middle Aged , Sputum/microbiologyABSTRACT
BACKGROUND: Hematopoietic stem cell transplant (HSCT) recipients have increased morbidity from respiratory viral infections. Pandemic influenza A - A(H1N1)/pdm09 - in 2009-2010 was associated with increased severity of illness in patients with underlying co-morbidities including HSCT, but the factors that contribute to severe disease in HSCT patients are not well characterized. METHODS: We conducted a multicenter review of microbiologically proven influenza A(H1N1)pdm09 in the HSCT population between April 2009 and April 2010 to determine factors that are associated with severe disease. RESULTS: We identified 37 adult patients (26 allogeneic and 11 autologous HSCT recipients). Median time from transplant to diagnosis was 411 days (range 4 days-14.9 years). Three cases were hospital acquired. Twenty-eight of 37 (75.7%) had confirmed A(H1N1)pdm09. Presumed viral lower respiratory tract infection was present in 12/37 (32.4%) patients. Antiviral therapy was given to 33/37 (89%) patients, primarily oseltamivir (n = 24) and oseltamivir before or after another antiviral (n = 8). Excluding those with nosocomial A(H1N1)pdm09, 18/34 (52.9%) were hospitalized and 6 (33%) required admission to an intensive care unit. Mortality within 30 and 60 days of symptom onset was 7/37 (18.9%) and 11/37 (29.7%), respectively. Factors associated with mortality included nosocomial acquisition (P = 0.023), receipt of mycophenolate mofetil (P = 0.001), or antilymphocyte antibody (P = 0.005) within the past 6 months, reduced-intensity conditioning (P = 0.027), and bacteremia (P = 0.021). CONCLUSIONS: A(H1N1)pdm09 infection was particularly severe in HSCT recipients, specifically among those receiving augmented immunosuppression for graft-versus-host disease. The high mortality of the nosocomial cases highlights the need for strict infection-control measures in hospitals during influenza outbreaks.
Subject(s)
Antiviral Agents/therapeutic use , Hematopoietic Stem Cell Transplantation/adverse effects , Influenza A Virus, H1N1 Subtype/isolation & purification , Influenza, Human/epidemiology , Pandemics , Adult , Aged , Cross Infection/complications , Cross Infection/drug therapy , Cross Infection/epidemiology , Female , Graft vs Host Disease/drug therapy , Graft vs Host Disease/epidemiology , Hospitalization , Humans , Infection Control , Influenza, Human/complications , Influenza, Human/drug therapy , Male , Middle Aged , Oseltamivir/therapeutic use , Risk Factors , Treatment Outcome , Young AdultABSTRACT
Although Trypanosoma cruzi, the parasite that causes Chagas disease, can be transmitted via organ transplantation, liver and kidney transplantation from infected donors may be feasible. We describe the outcomes of 32 transplant recipients who received organs from 14 T. cruzi seropositive donors in the United States from 2001 to 2011. Transmission was confirmed in 9 recipients from 6 donors, including 3 of 4 (75%) heart transplant recipients, 2 of 10 (20%) liver recipients and 2 of 15 (13%) kidney recipients. Recommended monitoring posttransplant consisted of regular testing by PCR, hemoculture, and serology. Thirteen recipients had no or incomplete monitoring; transmission was confirmed in five of these recipients. Four of the five recipients had symptomatic disease and all four died although death was directly related to Chagas disease in only one. Nineteen recipients had partial or complete monitoring for T. cruzi infection with weekly testing by PCR, hemoculture and serology; transmission was confirmed in 4 of 19 recipients with no cases of symptomatic disease. Our results suggest that liver and kidney transplantation from T. cruzi seropositive donors may be feasible when the recommended monitoring schedule for T. cruzi infection is followed and prompt therapy with benznidazole can be administered.
Subject(s)
Chagas Disease/transmission , Organ Transplantation/adverse effects , Adult , Aged , Chagas Disease/drug therapy , Chagas Disease/immunology , Female , Humans , Male , Middle Aged , Nitroimidazoles/therapeutic use , Polymerase Chain Reaction , Tissue Donors , Trypanosoma cruzi/immunology , United StatesABSTRACT
Necrotizing soft tissue infections (NSTI) are rare but carry high mortality rates. NSTI with Klebsiella species have been previously described as associated with Klebsiella liver abscesses and endophthalmitis. Here, we describe 6 cases of NSTI in liver transplant recipients associated with Klebsiella pneumoniae, 4 of which were K. pneumoniae carbapenemase (KPC)-producing K. pneumoniae (CRKP). Increased awareness of this emerging pathogen and its association with necrotizing skin and soft tissue infection is critical, as early recognition and debridement may improve survival. Antimicrobial treatment of CRKP infections remains an ongoing challenge and implementation of enhanced infection control measures is essential.
Subject(s)
Bacterial Proteins/biosynthesis , Klebsiella Infections/microbiology , Klebsiella pneumoniae/isolation & purification , Liver Transplantation/adverse effects , Skin Diseases, Bacterial/microbiology , Soft Tissue Infections/microbiology , beta-Lactamases/biosynthesis , Adult , Anti-Bacterial Agents/pharmacology , Carbapenems/pharmacology , Fatal Outcome , Female , Humans , Klebsiella Infections/drug therapy , Klebsiella Infections/pathology , Klebsiella pneumoniae/drug effects , Klebsiella pneumoniae/enzymology , Male , Middle Aged , Risk Factors , Skin Diseases, Bacterial/drug therapy , Skin Diseases, Bacterial/pathology , Soft Tissue Infections/drug therapy , Soft Tissue Infections/pathology , beta-Lactam ResistanceABSTRACT
Donor-derived fungal infections can be associated with serious complications in transplant recipients. Most cases of donor-derived candidiasis have occurred in kidney transplant recipients in whom contaminated preservation fluid is a commonly proposed source. Donors with cryptococcal disease, including those with unrecognized cryptococcal meningoencephalitis may transmit the infection with the allograft. Active histoplasmosis or undiagnosed and presumably asymptomatic infection in the donor that had not resolved by the time of death can result in donor-derived histoplasmosis in the recipient. Potential donors from an endemic area with either active or occult infection can also transmit coccidioidomycosis. Rare instances of aspergillosis and other mycoses, including agents of mucormycosis may also be transmitted from infected donors. Appropriate diagnostic evaluation and prompt initiation of appropriate antifungal therapy are warranted if donor-derived fungal infections are a consideration. This document discusses the characteristics, evaluation and approach to the management of donor-derived fungal infections in organ transplant recipients.
Subject(s)
Mycoses/complications , Organ Transplantation , Practice Guidelines as Topic , Tissue Donors , Antifungal Agents/therapeutic use , Humans , Mycoses/drug therapy , United StatesABSTRACT
Dematiaceous fungi are an opportunistic pathogen seen in solid organ transplant recipients. We report 2 cases of Exophiala infection and review the medical literature to summarize the spectrum of disease this pathogen can cause in this patient population.
Subject(s)
Antifungal Agents/therapeutic use , Dermatomycoses , Exophiala/isolation & purification , Kidney Transplantation/adverse effects , Aged , Arm/pathology , Dermatomycoses/diagnosis , Dermatomycoses/drug therapy , Dermatomycoses/microbiology , Dermatomycoses/surgery , Exophiala/drug effects , Fatal Outcome , Humans , Male , Skin/microbiology , Skin/pathology , Treatment OutcomeABSTRACT
We describe a case of nevirapine-induced Stevens-Johnson Syndrome (SJS) and fulminant hepatic failure (FHF) requiring liver transplantation. Five weeks prior to admission, a 57-year-old female with HIV infection had been switched to a nevirapine-based regimen of highly active antiretroviral therapy (HAART) with a CD4 cell count of 695/mm(3). Examination of the explanted native liver at initial transplantation revealed massive hepatic necrosis consistent with drug-induced liver injury. Primary graft nonfunction complicated the early postoperative course and liver retransplantation was required. On follow-up 2 years later, she remains in good health with an undetectable viral load on an efavirenz-based regimen of HAART. To our knowledge, this is the first report of successful liver transplantation following SJS and FHF.