Abstract
The incidence of infectious complications, compared with the general population and the pre-transplant status of the recipient, increases substantially following kidney transplantation, causing significant morbidity and mortality. The potent immunosuppressive therapy given to prevent graft rejection in kidney transplant recipients results in an increased susceptibility to a wide range of opportunistic infections including bacterial, viral and fungal infections. Over the last five years, several advances have occurred that may have changed the burden of infectious complications in kidney transplant recipients. Due to the availability of direct-acting antivirals to manage donor-derived hepatitis C infection, this has opened the way for donors with hepatitis C infection to be considered in the donation process. In addition, there have been the development of medications targeting the growing burden of resistant cytomegalovirus, as well as the discovery of the potentially important role of the gastrointestinal microbiota in the pathogenesis of post-transplant infection. In this narrative review, we will discuss these three advances and their potential implications for clinical practice.
Highlights
Kidney transplant recipients have a greatly increased risk of infection-related morbidity and mortality compared with the general population and the pre-transplant status of the recipient [1].Worldwide, the incidence of infectious complications following kidney transplantation has been reported to range between 49 to 80% [1]
In a study of 7344 adult patients with chronic HepatitisC virus (HCV) infection enrolled from hepatology centers in France who were followed up for approximately months, it was found that direct-acting anti-HCV (DAA) were associated with lower mortality (adjusted hazards ratio (HR) 0.48, 95% CI 0.33–0.70) and hepatocellular carcinoma rates and were not associated with decompensated cirrhosis [28]
This study showed a cost-effectiveness ratio of $56,018 per quality adjusted life years (QALY) from the payer perspective and $4647 per QALY from the societal perspective, compared with recipients who would otherwise have remained on dialysis for an additional year [44]
Summary
Kidney transplant recipients have a greatly increased risk of infection-related morbidity and mortality compared with the general population and the pre-transplant status of the recipient [1]. The incidence of infectious complications following kidney transplantation has been reported to range between 49 to 80% [1] This increased risk is likely due to various immunosuppressive. New treatments for donor-transmitted infections, such as direct acting antiviral drugs for HCV, substantially mitigate this risk [4]. There is emerging evidence that kidney transplant recipients may have significantly altered gastrointestinal microbiota, which in turn may be associated with increased risks of infection as a result of transmural migration of bowel micro-organisms, altered immunosuppressive medication pharmacokinetics and progressive kidney disease [6,7,8]. This review will discuss these three recent, key, promising, innovative approaches to potentially mitigating infectious burden in kidney transplant recipients through direct acting antiviral drugs targeting HCV, new treatments for CMV resistance, and therapeutic manipulation of the gut microbiota
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