Update on Guidelines for Prevention and Management of Mycobacterium Tuberculosis Infections After Transplant

Abstract

To the Editor: We applaud the relevant and useful guidelines recently published in the journal. However, a study published in the journal (1Klote MM Agodoa LY Abbott K Mycobacterium tuberculosis infection incidence in hospitalized renal transplant patients in the United States, 1998–2000..Am J Transplant. 2004; 4: 1523-1528Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar), too recently to be included in the guidelines, provides useful additional context and background for the guidelines on Mycobacterium tuberculosis (MTB). Relying on previously published data, which until recently did not include many reports from the United States, the authors state, 'rates of tuberculosis reported in the transplant literature often reflect the cumulative rates in patients followed over a number of years and cannot always be compared with or converted to annual incidence rates.' In addition, the authors state 'few risk factors have been defined for the occurrence of tuberculosis after transplantation. Surprisingly, only 20–25% of all cases of tuberculosis occurring after transplantation are in patients who have positive tuberculosis skin reactions before transplantation.' The report by Klote et al., which performed a retrospective cohort analysis on the UNOS renal transplant recipients from 1998 to 2000, gives a truly population based incidence of MTB of 2.5 cases per 1000 years at risk, or 0.3% in the first year after transplant. The only independent risk factor for post-transplant MTB was a diagnosis of systemic lupus erythematosus at the time of listing for transplant; patients with systemic lupus erythematosus prior to transplant had over four times the risk of MTB compared with all other patients. In addition, the development of MTB was independently associated with an increased risk of death; 23% of patients died within 1 year of diagnosis of MTB. Thus, while uncommon, MTB infection after transplant was associated with substantial mortality, and a diagnosis of systemic lupus erythematosus was identified as a previously underecognized risk factor.