Recipient Risk Factors Research Articles

Ocular infections after penetrating keratoplasty

Context Early diagnosis of ocular infections following penetrating keratoplasty (PK) depending on clinical presentation in addition to ancillary laboratory investigations facilitates preservation of useful vision and prevention of further intraocular spread. Aim The aim of this research was to study donor and recipient risk factors in post-PK ocular infections. Patients and methods This is an interventional prospective study. This prospective study was conducted in 34 patients who underwent PK under peribulbar anaesthesia from 2014 to 2016 in a tertiary hospital. Six patients developed signs and symptoms suspicious of postoperative infections. Inclusion and exclusion criteria are mentioned. MS excel was used for statistical analyses. Results The mean age was 53±18.04 years, ranging from 12 to 86 years with 24 (70.59%) male and 10 (29.41) female individuals studied. There were 24 (70.59%) right eyes and 10 left eyes (29.41). The mean age was 63.97±16.8 years among the donors. Six (17.64%) patients developed postoperative infections that included one patient with Pseudomonas aeroginosa keratoconjunctivitis, two patients with fusarium fungal keratitis and growth could not be established in the remaining three cases. Positive microbial identification by culture was possible in three (8.82%) patients. Conclusion Microbial identification was confirmed in three cases, and three cases were negative for growth. The risk factor found among recipients were vegetative injury, dust fall and eye rubbing, as well as taking a very hot bath. Graft clarity restoration significantly improved after topical management with fortified antibiotics and antifungal agents.

Prevalence and risk factors for posttransplant diabetes mellitus: Data from government tertiary care center

Background: Diabetes occurs in substantial number of patients following renal transplantation, contributing to mortality and morbidity in particular the cardiovascular disease and infection. The prevalence and risk factors in South Indian population is not precisely clear. Our study aimed at determining the prevalence, epidemiology, and risk factors in kidney transplant recipients with posttransplant diabetes mellitus (PTDM). Methodology: This is a single-center analytical, cross-sectional, and retrospective study of adult renal transplant recipients who underwent transplant between January 2014 and December 2016. Institutional ethics committee approval was obtained. Results: Of 149 patients transplanted, 115 were included for study. Twenty-six patients (22.6%) developed PTDM. The mean age of the PTDM group was 35.2 years and 76.92% were males. Univariate analysis revealed age (P 1 year (OR = 1.75), and induction therapy (OR = 2.0) to be independent risk factors for PTDM. Conclusions: There is high risk of developing diabetes after transplant with one quarter of this south Indian cohort developing PTDM. Older age, male sex, family history of diabetes, dialysis vintage, and use of induction therapy were independent risk factors for PTDM.

Early Outcomes of the New UK Deceased Donor Kidney Fast-Track Offering Scheme.

The UK Kidney Fast-Track Scheme (KFTS) was introduced in 2012 to identify kidneys at high risk of discard and to rapidly facilitate transplantation. A retrospective analysis of kidneys transplanted through the KFTS was undertaken. UK Transplant Registry data were collected on deceased donor kidneys implanted between November 1, 2012, and April 30, 2015, (donation after brain death [DBD] donors) and March 1, 2013, and April 30, 2015 (donation after circulatory death [DCD] donors). Posttransplant outcomes included 1-year estimated glomerular filtration rate and death-censored graft survival (DCGS). Over the study period, 523 deceased donor kidneys were transplanted through the KFTS and 4174 via the standard National Kidney Allocation Scheme (NKAS). Kidneys in the KFTS were more likely to be from older diabetic donors, had a higher frequency of poor ex vivo perfusion, had longer cold ischemic times, and were transplanted into older recipients. One-year DCGS of KFTS and NKAS DBD donor kidneys was similar (94% vs 95%; P = 0.70), but for DCD donor kidneys, DCGS was lower in those allocated via the KFTS (91% versus 95%; P = 0.04). Median 1-year estimated glomerular filtration rate for DBD donor kidneys was lower in those allocated via the KFTS (49 vs 52 mL/min per 1.73 m; P = 0.01), but for DCD kidneys, there was no difference (45 vs 48 mL/min per 1.73 m; P = 0.10). Although KFTS kidneys have less favorable donor, graft, and recipient risk factors than NKAS kidneys, short-term graft and patient outcomes are acceptable. National schemes that identify and rapidly offer kidneys at high risk of discard may contribute to minimizing the unnecessary discard of organs.

Heart Transplantation and Risk of Cardiac Vasculopathy Development: What Factors Are Important?

BackgroundThe aim of this study was to find the main risk factors for development of cardiac allograft vasculopathy (CAV), especially factors identified before the surgical procedure and factors related to the recipient profile and the medical history of the donor.Material/MethodsThere were 147 patients who had heart transplantation (HT) included in this study: mean age was 45.8±15.3 years. All study patients had coronary angiography after HT. Analyzed risk factors were: non-immunologic recipient risk factors (age of transplantation, smoking, hypertension, lipids, diabetes, obesity and weight gain after HT), immunologic recipient risk factors (acute cellular rejection (ACR), acute humoral rejection (AMR), cytomegalovirus (CMV) episodes), and donor-related risk factors (age, sex, catecholamine usage, ischemic time, compatibility of sex and blood groups, cause of death, cardiac arrest).ResultsCAV was recognized in 48 patients (CAV group); mean age 53.6±13.6 years. There were 99 patients without CAV (nonCAV group); mean age 48.3±15.5 years. A univariate Cox analysis of the development of coronary disease showed statistical significance (p<0.05) for baseline high-density lipid (HDL), ACR, AMR, CMV, and donor age. Multivariate Cox regression model confirmed that only baseline HDL, episodes of ACR, donor age, and CMV infection are significant for the frequency of CAV after HT.ConclusionsOlder donor age is highly associated with CAV development. Older donor age and low level of HDL in heart recipients with the strongest influence of immunologic risk factors (ACR, CMV infection) were linked with development of CAV.

Liver transplant length of stay (LOS) index: A novel predictive score for hospital length of stay following liver transplantation.

An index to predict hospital length of stay after liver transplantation could address unmet clinical needs. Length of stay is an important surrogate for hospital costs and efforts to limit stays can preserve our healthcare resources. Here, we devised a scoring system that predicts hospital length of stay following liver transplantation. We used univariate and multivariate analyses on 73635 adult liver transplant recipient data and identified independent recipient and donor risk factors for prolonged hospital stay (>30days). Multiple imputation was used to account for missing variables. We identified 22 factors as significant predictors of prolonged hospital stay, including the most significant risk factors: intensive care unit (ICU) admission (OR 1.75, CI 1.58-1.95) and previous transplant (OR 1.60, CI 1.47-1.75). The length of stay (LOS) index assigns weighted risk points to each significant factor in a scoring system to predict prolonged hospital stay after liver transplantation with a c-statistic of 0.75. The LOS index demonstrated good discrimination across the entire population, dividing the cohort into tertiles, which had odds ratios of 2.25 (CI 2.06-2.46) and 7.90 (7.29-8.56) for prolonged hospital stay (>30days). The LOS index utilizes 22 significant donor and recipient factors to accurately predict hospital length of stay following liver transplantation. The index further demonstrates the basis for a clear clinical recommendation to mitigate risk of long hospitalization by minimizing cold ischemia time.

Predicting 1-year cardiac transplantation survival using a donor–recipient risk-assessment tool

ObjectiveMany donor and recipient factors influence 1-year survival of patients after cardiac transplantation. To date, a statistical model has not been developed to assess the interplay of these factors in predicting outcomes, so we developed a risk-assessment tool to enhance decision-making. MethodsWe analyzed 29 variables that were reported in the United Network for Organ Sharing database for 24,540 cardiac transplantations performed between January 1, 2000, and June 30, 2015. For one half of the patients (the prediction population), a multivariable Cox regression model and the bootstrap resampling method were used to devise a scoring system predicting 1-year survival. The other half (the validation population) were stratified by score into 3 risk categories: high risk, medium risk, and low risk. One-year survival was compared among the 3 groups. ResultsEleven variables were statistically significant in predicting 1-year survival. One-year survival for patients with risk scores of less than or equal to 8, 9 to 15, and greater than 15 were 91.2%, 81.7%, and 64.6%, respectively (P < .001). The C index of the Cox regression model was calculated at 0.62 when using risk score as a continuous predictor. ConclusionsDonor and recipient risk factors influence patient survival after cardiac transplantation. Long-term outcomes may be optimized with a statistically based risk model to improve donor–recipient matching.

Clinical Risk Factors and Prognostic Model for Primary Graft Dysfunction after Lung Transplantation in Patients with Pulmonary Hypertension.

Pulmonary hypertension from pulmonary arterial hypertension or parenchymal lung disease is associated with an increased risk for primary graft dysfunction after lung transplantation. We evaluated the clinical determinants of severe primary graft dysfunction in pulmonary hypertension and developed and validated a prognostic model. We conducted a retrospective cohort study of patients in the multicenter Lung Transplant Outcomes Group with pulmonary hypertension at transplant listing. Severe primary graft dysfunction was defined as PaO2/FiO2 ≤200 with allograft infiltrates at 48 or 72 hours after transplantation. Donor, recipient, and operative characteristics were evaluated in a multivariable explanatory model. A prognostic model derived using donor and recipient characteristics was then validated in a separate cohort. In the explanatory model of 826 patients with pulmonary hypertension, donor tobacco smoke exposure, higher recipient body mass index, female sex, listing mean pulmonary artery pressure, right atrial pressure and creatinine at transplant, cardiopulmonary bypass use, transfusion volume, and reperfusion fraction of inspired oxygen were associated with primary graft dysfunction. Donor obesity was associated with a lower risk for primary graft dysfunction. Using a 20% threshold for elevated risk, the prognostic model had good negative predictive value in both derivation and validation cohorts (89.1% [95% confidence interval, 85.3-92.8] and 83.3% [95% confidence interval, 78.5-88.2], respectively), but low positive predictive value. Several recipient, donor, and operative characteristics were associated with severe primary graft dysfunction in patients with pulmonary hypertension, including several risk factors not identified in the overall transplant population. A prognostic model with donor and recipient clinical risk factors alone had low positive predictive value, but high negative predictive value, to rule out high risk for primary graft dysfunction.

Risk Factors and Expected Clinical Outcomes in Kidney Transplantation Based on 1 Year Serum Creatinine Levels

Background: This retrospective study delineates the variable risk factors associated with differences in renal function at 1 year post kidney transplantation. Materials and Methods:<b> </b>Two hundred and eighty four<b> </b>kidney transplant patients were reviewed and divided into 4 groups according to serum creatinine levels 1 year post kidney transplantation: serum creatinine levels < 1 mg/dl (Group I; 65 patients), serum creatinine between 1 and 1.51 mg/dl (Group II; 173 patients), serum creatinine between 1.51 and 2mg/dl (Group III; 37 patients) and serum creatinine > 2mg/dl (Group IV; 9 patients). Baseline demographics and variable risk factors in both donors and recipients were analyzed. Results:<b> </b>Baseline demographics of all groups were similar, including: recipient age, cause of the original kidney disease, dialysis duration, HLA matching, induction therapy, rate of acute rejection as well as the pre and 1 year post transplant diabetes, hypertension and lipid profile. However, there were significant differences between the groups according to: donor age, donor and recipient gender, maintenance immunosuppression therapy, recipient sensitization and the severity of acute rejection episodes. The rate and type of In Hospital infections, the duration of hospital stay, the occurrence of delayed graft function, the rate and type of surgical complications at 1 year as well as the serum creatinine levels upon discharge and at 1, 3 and 6 months were significantly different between the 4 groups. Conclusion:<b> </b>Serum creatinine level post-transplantation is a powerful predictor of long term graft survival. Although some risk factors associated with graft survival are fixed, others can be optimized.

Negativization of viremia prior to liver transplant reduces early allograft dysfunction in hepatitis C-positive recipients.

Although early allograft dysfunction (EAD) negatively impacts survival from the first months following liver transplantation (LT), direct-acting antiviral agents (DAAs) have revolutionized hepatitis C virus (HCV) therapy. We investigated the EAD definition best predicting 90-day graft loss and identified EAD risk factors in HCV-positive recipients. From November 2002 to June 2016, 603 HCV-positive patients (hepatocellular carcinoma, 53.4%) underwent a first LT with HCV-negative donors. The median recipient Model for End-Stage Liver Disease (MELD) score was 15, and the median donor age was 63 years. At LT, 77 (12.8%) patients were HCV RNA negative; negativization was achieved and maintained by pre-LT antiviral therapy (61 patients) or pre-LT plus a pre-emptive post-LT course (16 patients); 60 (77.9%) patients received DAAs and 17 (22.1%) interferon. We compared 3 different EAD definitions: (1) bilirubin ≥ 10 mg/dL or international normalized ratio ≥ 1.6 on day 7 after LT or aspartate aminotransferase or alanine aminotransferase > 2000 IU/L within 7 days of LT; (2) bilirubin > 10 mg/dL on days 2-7 after LT; and (3) MELD ≥ 19 on day 5 after LT. EAD defined by MELD ≥ 19 on day 5 after LT had the lowest negative (0.1) and the highest positive (1.9) likelihood ratio to predict 90-day graft loss. At 90 days after LT, 9.2% of recipients with EAD lost their graft as opposed to 0.7% of those without EAD (P < 0.001). At multivariate analysis, considering variables available at LT, MELD at LT of >25 (OR = 7.4) or 15-25 (OR = 3.2), graft macrovesicular steatosis ≥ 30% (OR = 6.7), HCV RNA positive at LT (OR = 2.7), donor age > 70 years (OR = 2.0), earlier LT era (OR = 1.8), and cold ischemia time ≥ 8 hours (OR = 1.8) were significant risk factors for EAD. In conclusion, in HCV-positive patients, MELD ≥ 19 on day 5 after LT best predicts 90-day graft loss. Preventing graft infection by pre-/peri-LT antiviral therapy reduces EAD incidence and could be most beneficial in high-MELD patients and recipients of suboptimal grafts. Liver Transplantation 23 915-924 2017 AASLD.

Report From the American Society of Transplantation Conference on Donor Heart Selection in Adult Cardiac Transplantation in the United States.

Cardiac transplantation remains the only definitive treatment for end-stage heart failure. Transplantation rates are limited by a shortage of donor hearts. This shortage is magnified because many hearts are discarded because of strict selection criteria and concern for regulatory reprimand for less-than-optimal posttransplant outcomes. There is no standardized approach to donor selection despite proposals to liberalize acceptance criteria. A donor heart selection conference was organized to facilitate discussion and generate ideas for future research. The event was attended by 66 participants from 41 centers with considerable experience in cardiac donor selection. There were state-of-the-art presentations on donor selection, with subsequent breakout sessions on standardizing the process and increasing utilization of donor hearts. Participants debated misconceptions and established agreement on donor and recipient risk factors for donor selection and identified the components necessary for a future donor risk score. Ideas for future initiatives include modification of regulatory practices to consider extended criteria donors when evaluating outcomes and prospective studies aimed at identifying the factors leading to nonacceptance of available donor hearts. With agreement on the most important donor and recipient risk factors, it is anticipated that a consistent approach to donor selection will improve rates of heart transplantation.

Food and dietary behaviours as cardiometabolic risk factors in liver transplant recipients

Food and dietary behaviours as cardiometabolic risk factors in liver transplant recipients

Differentiating pulmonary transfusion reactions using recipient and transfusion factors.

It is increasingly recognized that recipient risk factors play a prominent role in possible transfusion-related acute lung injury (pTRALI) and transfusion-associated circulatory overload (TACO). We hypothesized that both transfusion and recipient factors including natriuretic peptides could be used to distinguish TRALI from TACO and pTRALI. We performed a post hoc analysis of a case-control study of pulmonary transfusion reactions conducted at the University of California at San Francisco and Mayo Clinic, Rochester. We evaluated clinical data and brain natriuretic peptides (BNP) levels drawn after transfusion in patients with TRALI (n = 21), pTRALI (n = 26), TACO (n = 22), and controls (n = 24). Logistic regression and receiver operating characteristics curve analyses were used to determine the accuracy of clinical and biomarker predictors in differentiating TRALI from TACO and pTRALI. We found that pTRALI and TACO were associated with older age, higher fluid balance, and elevated BNP levels relative to those of controls and TRALI. The following variables were useful in distinguishing cases of pTRALI and TACO from TRALI: age more than 70 years, BNP levels more than 1000 pg/mL, 24-hour fluid balance of more than 3 L, and a lower number of transfused blood components. Using the above variables, our logistic model had a 91% negative predictive value in the differential diagnosis of TRALI. Models incorporating readily available clinical and biomarker data can be used to differentiate transfusion-related respiratory complications. Additional studies examining recipient risk factors and the likelihood of TRALI may be useful in decision making regarding donor white blood cell antibody testing.

Clinical relevance of the International Society for Heart and Lung Transplantation consensus classification of primary graft dysfunction after heart transplantation: Epidemiology, risk factors, and outcomes

Primary graft dysfunction (P-GD) is the leading cause of early mortality after heart transplantation (HT). In this 2-center study we analyze outcomes and risk factors of P-GD according to the recent consensus conference classification endorsed by International Society for Heart and Lung Transplantation. We included all adult HTs performed between 1999 and 2013. P-GD was graded as mild, moderate, and severe, according to International Society for Heart and Lung Transplantation recommendations, and analyzed separately from secondary GD. The primary end point was the combined occurrence of in-hospital death or emergency retransplantation. Early GD was found in 118 of 518 patients (23%), and 72 (13.9%) met the criteria for P-GD. Of these, 4 (5%) were mild, 33 (46%) moderate, and 35 (49%) severe and mostly characterized by biventricular involvement (78%). The end point occurred in 53 patients (10.2%). Overall, GD was a strong predictor of death-graft loss (odds ratio, 15.9; 95% confidence interval, 7.9-33.5; p < 0.01), with non-significant worse outcomes in P-GD (37%) vs secondary GD (27%) patients (p = 0.2). The study end point was more frequent in severe P-GD patients (65%) than in moderate (12%) or mild (0%; p < 0.01). Several known risk factors influenced the risk for P-GD, and the combination of specific donor and recipient risk factors accounted for approximately 22-times increased odds for P-GD. Donor age, recipient diabetes, ischemic time, and post-operative dialysis predicted non-recovery from P-GD. Consensus-defined P-GD identifies patients at major risk for early death and graft loss after HT, although the "mild" grade appeared under-represented and clinically irrelevant. The amplified negative effect of donor and recipient factors on P-GD risk underscores the need for appropriate donor-recipient match.

Effect of Right Posterior Bile Duct Anatomy on Biliary Complications in Patients Undergoing Right Lobe Living Donor Liver Transplant.

Our aim was to evaluate the influence of the localization of right posterior bile duct anatomy relative to portal vein of the donors on posttransplant bile duct complications. We retrospectively investigated 141 patients who had undergone living donor liver transplant using right hemiliver grafts. The patients were classified based on the pattern of the right posterior bile duct and divided into infraportal and supraportal types. Clinical donor and recipient risk factors and surgical outcomes were compared for their relationship with biliary complications using logistic regression analyses. The 2 groups were similar according to demographic and clinical features. The biliary complication rate was 23.7% (9/38) in the infraportal group and 47.4% (37/78) in the supraportal group (P = .014). An analysis of risk factors for the development of anastomotic bile leak using logistic regression showed that a supraportal right posterior bile duct anatomy was a statistically significant positive predictor, with odds ratio of 18.905 (P = .012; confidence interval, 1.922-185.967). The distance of the right posterior bile duct from confluence was significantly lower in patients with biliary complications than in those without (mean of 7.66 vs 0.40 mm; P = .044). According to receiver operating characteristic analyses, the cut-off point for the length of right bile duct to right posterior bile duct from the hepatic confluence was 9.5 mm regarding presence of complications. Factors influencing bile duct anastomosis leakage were supraportal-type donor bile duct anatomy and length of the right main bile duct from biliary confluence. Hepatic arterial complications were similarly a risk factor for biliary strictures. Because of the multiple factors leading to complications in living donor liver transplant, it is challenging to group these patients by operative risk; however, establishing risk models may facilitate the prediction of complications.

Protein biomarkers associated with primary graft dysfunction following lung transplantation.

Severe primary graft dysfunction affects 15-20% of lung transplant recipients and carries a high mortality risk. In addition to known donor, recipient, and perioperative clinical risk factors, numerous biologic factors are thought to contribute to primary graft dysfunction. Our current understanding of the pathogenesis of lung injury and primary graft dysfunction emphasizes multiple pathways leading to lung endothelial and epithelial injury. Protein biomarkers specific to these pathways can be measured in the plasma, bronchoalveolar lavage fluid, and lung tissue. Clarification of the pathophysiology and timing of primary graft dysfunction could illuminate predictors of dysfunction, allowing for better risk stratification, earlier identification of susceptible recipients, and development of targeted therapies. Here, we review much of what has been learned about the association of protein biomarkers with primary graft dysfunction and evaluate this association at different measurement time points.

Re-evaluating Cut-off Points for the Expansion of Deceased Donor Criteria for Kidney Transplantation in Japan

BackgroundA shortage of donors poses a serious problem for organ transplantation around the world. In response, the concept of the expanded criteria donor (ECD) has been defined to include donors with traditionally less favorable characteristics. That definition has now been accepted and is being applied in kidney transplantation in the United States and Europe. However, the ECD has not yet been defined for deceased donor kidney transplantation in Japan. Patients and MethodsWe analyzed data on graft survival and relevant risk factors in patients who received deceased donor kidney transplants through the East Japan Branch of the Japan Organ Transplant network (n = 1051). Recipients were divided into two groups: the standard-function group (estimated glomerular filtration rate [eGFR] ≥20 mL/min/1.73 m2; n = 906) and the poor-function group (eGFR <20 mL/min/1.73 m2; n = 145; Cox proportional hazards regression analysis; P < .0001). ResultsThe 10-year survival rate was significantly lower in the poor-function group than in the standard-function group (85.5% vs 22.5%; P < .0001). The two groups differed significantly in recipient and donor risk for graft failure. Recipient risk factors were length of time on dialysis before renal transplantation and incidence of acute rejection after transplantation. Donor risk factors were donor category (heart death), age, history of hypertension, presence of cerebrovascular disease, mean urine output, and donor creatinine level immediately before donor nephrectomy, total ischemic time, and warm ischemic time. ConclusionData from deceased donor transplantation should be analyzed in depth to determine which factors influence renal function after transplantation. In addition, ECD standards should be reconsidered for use in a Japanese context.

Prevalence of the metabolic syndrome in kidney transplant recipients: A single-center study.

Metabolic syndrome (MS) is characterized by a combination of cardiovascular (CV) risk factors (hypertension, dyslipidemia, obesity, and alterations in glucose homeostasis). Insulin resistance is suggested to be the common pathogenic background. This syndrome is also a risk factor for diabetes and chronic kidney disease. In renal transplant recipients, MS has been shown to be an independent risk factor for chronic allograft dysfunction, graft failure, new-onset diabetes, and CV disease. We performed a cross-sectional study on 106 stable renal transplant recipients to detect MS between January 2013 and August 2013. This syndrome was diagnosed according to the National Cholesterol Education Program-Adult Treatment Panel III criteria. Patients with history of diabetes mellitus were excluded from the study. In this group of patients, 56 (52.8%) had MS. There were 32 males (57.1%) and 24 females (42.9%). The mean age of the MS group was significantly higher than the non-MS group. The mean serum creatinine was higher in the MS group than the non-MS group, but there was no significant difference between them (P >0.05). The calculated glomerular filtration rate was also similar in the two groups (P >0.05). The patients with MS had higher body weight (64.61 ± 14.17 kg vs. 58.76 ± 11.70 kg, P <0.05) and also higher body mass index (BMI) (P <0.05). The prevalence of BMI >25 kg/m2 in the MS group was 75% versus 25% in the non-MS group (P <0.05). Since MS is an important and common risk factor in renal transplant recipients, we have to try to prevent it by educating the patients to control it by modifying their lifestyle. Efforts toward promoting healthy diets, physical activity, and blood pressure control must be undertaken.

Tuberculosis and Transplantation.

Mycobacterium tuberculosis is a major opportunistic pathogen in transplant recipients. Compared to that in the general population, the frequency of tuberculosis (TB) is 10 to 40 times higher in hematopoietic stem cell transplant (HSCT) recipients and 20 to 74 times higher in solid-organ transplant (SOT) recipients. Transplant recipients with TB are also more likely to develop disseminated disease, have longer time to definitive diagnosis, require more invasive diagnostic procedures, and experience greater anti-TB treatment-related toxicity than the general population. Specific risk factors for TB in SOT recipients include previous exposure to M. tuberculosis (positive tuberculin skin tests and/or residual TB lesions in pretransplant chest X ray) and the intensity of immunosuppression (use of antilymphocyte antibodies, type of basal immunosuppression, and intensification of immunosuppressive therapy for allograft rejection). Risk factors in HSCT recipients are allogeneic transplantation from an unrelated donor; chronic graft-versus-host disease treated with corticosteroids; unrelated or mismatched allograft; pretransplant conditioning using total body irradiation, busulfan, or cyclophosphamide; and type and stage of primary hematological disorder. Transplant recipients with evidence of prior exposure to M. tuberculosis should receive treatment appropriate for latent TB infection. Optimal management of active TB disease is particularly challenging due to significant drug interactions between the anti-TB agents and the immunosuppressive therapy. In this chapter, we address the epidemiology, clinical presentation, diagnostic considerations, and management strategies for TB in SOT and HSCT recipients.

Predicting risk factors for varicella zoster virus infection and postherpetic neuralgia after hematopoietic cell transplantation using ordered logistic regression analysis.

To identify risk factors for varicella zoster virus (VZV) infection and postherpetic neuralgia (PHN) after hematopoietic cell transplantation (HCT), we conducted a retrospective chart review of 163 consecutive patients who underwent HCT between November 2004 and July 2014. Overall, the male/female (M/F) ratio was 80/83, median age at HCT was 54 (range 15-69) years, and autologous/allogeneic HCT (auto/allo-HCT) ratio was 71/92. Forty-four patients [M/F, 25/19; median age, 57 (range: 16-68) years; auto/allo-HCT, 26/18] developed VZV infection after HCT. All cases were successfully treated with acyclovir (ACV) or valacyclovir, and there was no VZV-related death. Nine (20%) of the 44 patients [M/F, 5/4; median age, 58 (range: 21-63) years; auto/allo-HCT, 7/2] developed PHN after resolution of zoster. Multivariate ordered logistic analysis identified receiving immunosuppressive therapy at the cessation of ACV [odds ratio (OR)=74.53; 95% confidence interval (CI)=6.99-794.32; P=0.0004] as a risk factor for VZV infection and PHN in allo-HCT recipients. However, in auto-HCT recipients, only advanced age was identified as a risk factor (OR=1.06, 95% CI=1.002-1.127, P=0.0429). Our findings indicate receiving immunosuppressive therapy at the cessation of ACV is a significant risk factor for allo-HCT recipients, while advanced age is a significant risk factor for auto-HCT recipients.

Basic aspects of the pathogenesis and prevention of non-melanoma skin cancer in solid organ transplant recipients: a review.

As numbers of transplant recipients and survival rates increase, the vulnerability of this population to several malignancies also rises. Non-melanoma skin cancer (NMSC) carries the highest rates of morbidity and mortality in this population. To avoid these malignancies, it is necessary to identify particular risk factors in transplant recipients and to follow preventive protocols. The MEDLINE and EMBASE databases were reviewed using as keywords the medical subject headings (MeSH) "transplantation", "skin neoplasm" and "prevention". The search was limited to clinical trials, randomized clinical trials and case-control studies conducted during the previous 20 years. The most important risk factors for the development of NMSCs in the transplant recipient population are cumulative ultraviolet radiation exposure, use of immunosuppressive agents (especially azathioprine as a photosensitizing agent) and infections by human papillomaviruses. The use of sun protection and retinoids were identified as possible protective factors. Other potential therapies, such as antioxidants, difluormethylornithine and cyclooxygenase-2 inhibitors, require further study. Patient risk factors for the development of NMSC should be reviewed during the transplant consultation. Individuals found to be at increased risk should undergo closer follow-up and preventive care counseling. This article proposes an algorithm for the prevention of NMSC.