Invasive Aspergillosis After Kidney Transplant - Treatment Approach

Abstract

Aim: Aim of the article was to present a case of post transplantation invasive aspergillosis, successfully treated with conservative and surgical treatment. Case report: Patient, male, 44 years old, with second kidney transplant, required special preparation therapy, because he was sensitized, with concentration of Panel Reactive Antibody (PRA) class I 11% and PRA class II 76%. On the day of transplantation, induction was done with anti - thymocyte globulin ( ATG) and glucocorticosteroids. After transplantation, plasmapheresis with ATG was performed. On the fourth day patient was anuric. Fine-needle biopsy of the graft was performed and showed positive CD4 antibodies for peritubular capillaries and humoral rejection. 14 plasmaphereses through 14 days, were negative and ATG treatment was suspended completely. Full therapeutic dosage of tacrolimus and mycophenolate mofetil were given during treatment. Four days after treatment patient was stable, but next day clinical status had worsened with dyspnea and fever. In sputum, spores of Aspergillus species were microscopically found, and radiologically by computerised tomography. Caspofungin was administered for seven days. Voriconazole therapy was given for first ten days by intravenous route and after then orally. Even with this treatment, there was no improvement in clinical picture, while CT scan of the lungs showed abscess collection in right lung. Lobectomy was performed and pus collection was found. After graft-nephroctomy, patient was treated with continous veno-venous hemodiafiltration (CV-VHDF) dialyses, with constant voriconazole therapy for the next three months (200mg two times per day). After one month of diagnosis, Galactomannan (GM) test was negative. Conclusion: Although highly sensitized patients, those who are on hemodialysis, in preparation for transplantation, receive intensive immunosuppressive therapy that suppress the immune system. Occurrence of secondary fungal infections especially infection by aspergillosis, is cause of high mortality of infected. Application GM test that detects existence of antibodies against Aspergillus antigens and usage of different type of immunosuppressive preparation can increase longevity of graft and patients in solid organ transplantation program. Aspergillosis is treated with voriconazole and surgery, and sometimes graft-nephrectomy if needed. Recommendation is that in all immunocompromised hosts and organ transplant recipient should have been tested with GM test.

Invasive Aspergillosis in Post Kidney Transplant Patient: A Case Report

“…The effect of the newly introduced pathogens is particularly threatening in transplant patients and other immunesuppressed hosts [6] . Application GM test that detects existence of antibodies against Aspergillus antigens and usage of different type of immunosuppressive preparation can increase longevity of graft and patients in solid organ transplantation program [7] .…”

Invasive Aspergillosis after Renal Transplantation

“…Although the incidence rates are low at 0.5% in most published examples, they range from 0.2% to 14% in different studies [ 9 , 10 , 11 ]. It is also observed that the reported incidence of IA after renal transplantation varies from region to region across the globe.…”

“…A high mortality rate has been observed in IA in renal transplants (40–60%) [ 1 , 12 ]. In some studies, it is as high as 67% to 92%; however, this may be due to the small number of cases of these studies [ 7 , 11 , 13 ]. For example, Gavalda et al observed the death of 7 out of 10 renal transplant recipients with IA in his retrospective case–control study, a 70% mortality [ 13 ].…”

“…Meanwhile, some authors have suggested testing for GM before transplantation in recipients who will require aggressive immunosuppression [ 11 ].…”

“…Some authors recommend six–twelve weeks of administration of antifungals [ 15 ], while others recommend antifungals until two weeks after major clinical and radiological improvement. Some authors recommend 6 months of treatment with voriconazole after surgical treatment of IA [ 11 ]. Monitoring of GM and direct smear and cultures could be used to direct the decision of therapy discontinuation [ 15 ].…”