A practical approach to tuberculosis diagnosis and treatment in liver transplant recipients in a low-prevalence area

A Case Series of Extrapulmonary Mycobacterium in Liver Transplant Recipients

“…Rifampicin and pyrazinamide have been shown to be the most effective drugs for standard TB therapy but are not ideal to use in liver transplant recipients because of significant drug interactions and intrinsic hepatotoxicity. 8 Clinically significant hepatotoxicity is a well-described adverse effect of isoniazid, rifampin, and pyrazinamide. The combination of rifampicin/pyrazinamide is known to cause severe liver toxicity.…”

Fluoroquinolones for the treatment of latent Mycobacterium tuberculosis infection in liver transplantation

“…Screening requires collection of an exhaustive clinical history, a careful physical examination, a tuberculin skin test (TST) and/or tuberculosis interferon-γ release assay (IGRA), and a chest radiograph[21]. Isoniazid (2.5 to 5 mg/kg per day, without exceeding 300 mg/day) plus vitamin B6 (25 to 50 mg/day) for 9 mo is the traditional treatment of choice for LTBI in the SOT population[20,22,23] (Table 1). Treatment should ideally be started before LT, although in candidates with advanced end-stage liver disease, current clinical guidelines recommend different LTBI treatments until liver function is stable after LT[22,23].…”

“…Isoniazid (2.5 to 5 mg/kg per day, without exceeding 300 mg/day) plus vitamin B6 (25 to 50 mg/day) for 9 mo is the traditional treatment of choice for LTBI in the SOT population[20,22,23] (Table 1). Treatment should ideally be started before LT, although in candidates with advanced end-stage liver disease, current clinical guidelines recommend different LTBI treatments until liver function is stable after LT[22,23]. Another alternative to isoniazid is rifampicin for 4 months, although such a regimen should be restricted to the pretransplant period due to the risk of drug interactions with immunosuppressive agents.…”

“…Another alternative to isoniazid is rifampicin for 4 months, although such a regimen should be restricted to the pretransplant period due to the risk of drug interactions with immunosuppressive agents. Combination treatment with isoniazid/rifampicin for 3 to 4 months carries an important cumulative risk of fulminant hepatitis and should not be prescribed to patients with liver disease[22]. Two recent studies describing the experience with a 12-wk course of once-weekly directly observed therapy (DOT) with isoniazid plus rifapentine included 8 and 7 LT candidates[24,25] and reported adequate tolerance and a relatively high completion rate.…”

“…However, this delay could lead to an increased risk of TB reactivation, as most cases of active TB are diagnosed within the first months after transplantation[6,8,12]. Moreover, in candidates already receiving isoniazid-based LTBI treatment regimen, therapy must be stopped at the time of LT and resumed only when the allograft is stabilized[22], delaying the end of treatment.…”