Owing to liver toxicity with highly elevated liver function tests pyrazinamide had to be stopped and therapy was continued with rifampicin, isoniazid and ethambutol. Although all cultures became sterile after 1 month, a follow-up CAT scan showed persistent abdominal masses. Thus, triple therapy was extended to 3 months. A subsequent CAT scan showed remission of the abdominal masses and the kidney transplant function improved to a creatinine of 1.7 mg/dL at discharge (eGFR 39 mL/min MDRD). Also, anemia improved, and white blood cell count as well as lactate dehydrogenase decreased to normal range. Immunosuppressive therapy was slightly increased as mycophenolic acid was resumed at 180 mg twice per day, cyclosporine was continued with target levels of 30 to 50 ng/mL and prednisolone given at 5 mg/day. The patient was discharged, and intensive antibiotic therapy was followed by 8 months of rifampicin and isoniazid.
One year later, the patient was hospitalized again and died of severe cytomegalovirus pneumonia. All tests and cultures for mycobacterium tuberculosis were negative at that time.
Furthermore, the therapy in kidney transplant recipients is complicated by drug–drug interactions with immunosuppressive agents and is associated with the development of rejections.[11,22] Owing to the difficulties in diagnosis and treatment, the mortality of active tuberculosis in renal transplant recipients is still 6% to 10%[4,15] with about 15% graft loss and a median GFR decrease of 10 mL/min during therapy. In our case, the kidney transplant function even improved with therapy. This can partially be attributed to the reduction in cyclosporine doses but might also be because of renal involvement of tuberculosis, which is supported by the sterile pyuria.
In conclusion, this case demonstrates the variable and unspecific presentation of tuberculosis in kidney transplant recipients with its challenging diagnosis and illustrates that tuberculosis also constitutes a relevant complication in the later post-transplant course.
Christian Schmidt-Lauber orcid: 0000-0002-7864-0361.
. Muñoz P, Rodríguez C, Bouza E. Mycobacterium tuberculosis
infection in recipients of solid organ transplants. Clin Infect Dis 2005;40:581–7.
. Torre-Cisneros J, Doblas A, Aguado JM, et al. Tuberculosis
after solid-organ transplant: incidence, risk factors, and clinical characteristics in the RESITRA (Spanish Network of Infection in Transplantation) cohort. Clin Infect Dis 2009;48:1657–65.
. Singh N, Paterson DL. Mycobacterium tuberculosis
infection in solid-organ transplant recipients: impact and implications for management. Clin Infect Dis 1998;27:1266–77.
. Canet E, Dantal J, Blancho G, et al. Tuberculosis
following kidney transplantation
: clinical features and outcome. A French multicentre experience in the last 20 years. Nephrol Dial Transplant 2011;26:3773–8.
. Rathi P, Gambhire P. Abdominal tuberculosis
. J Assoc Physicians India 2016;64:38–47.
. Mazurek GH, Jereb J, Vernon A, et al. Updated guidelines for using Interferon Gamma Release Assays to detect Mycobacterium tuberculosis
infection—United States, 2010. MMWR Recomm Rep 2010;59:1–25.
. Klote MM, Agodoa LY, Abbott K. Mycobacterium tuberculosis
infection incidence in hospitalized renal transplant patients in the United States, 1998-2000. Am J Transplant 2004;4:1523–8.
. Pedotti P, Cardillo M, Rossini G, et al. Incidence of cancer after kidney transplant: results from the North Italy transplant program. Transplantation 2003;76:1448–51.
. Miyazaki T, Sato S, Kondo T, et al. National survey of de novo malignancy after solid organ transplantation in Japan. Surg Today 2018;48:618–24.
. Webster AC, Craig JC, Simpson JM, et al. Identifying high risk groups and quantifying absolute risk of cancer after kidney transplantation
: a cohort study of 15,183 recipients. Am J Transplant 2007;7:2140–51.
. Subramanian AK, Morris MI. AST Infectious Diseases Community of Practice. Mycobacterium tuberculosis
infections in solid organ transplantation. Am J Transplant 2013;13(suppl 4):68–76.
. Reis-Santos B, Gomes T, Horta BL, et al. Tuberculosis
prevalence in renal transplant recipients: systematic review and meta-analysis. J Bras Nefrol 2013;35:206–13.
. John GT, Shankar V, Abraham AM, et al. Risk factors for post-transplant tuberculosis
. Kidney Int 2001;60:1148–53.
. Ha YE, Joo EJ, Park SY, et al. Tacrolimus as a risk factor for tuberculosis
and outcome of treatment with rifampicin in solid organ transplant recipients. Transpl Infect Dis 2012;14:626–34.
. Ergun I, Ekmekci Y, Sengul S, et al. Mycobacterium tuberculosis
infection in renal transplant recipients. Transplant Proc 2006;38:1344–5.
. Benito N, García-Vázquez E, Horcajada JP, et al. Clinical features and outcomes of tuberculosis
in transplant recipients as compared with the general population: a retrospective matched cohort study. Clin Microbiol Infect 2015;21:651–8.
. Mycobacterium tuberculosis
. Am J Transplant 2004;4(suppl 10):37–41.
. EBPG Expert Group on Renal Transplantation. European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV.7.2. Late infections Tuberculosis
. Nephrol Dial Transplant 2002;17(suppl 4):39–43.
. Ferguson TW, Tangri N, Macdonald K, et al. The diagnostic accuracy of tests for latent tuberculosis
infection in hemodialysis patients: a systematic review and meta-analysis. Transplantation 2015;99:1084–91.
. Kim S-H, Lee S-O, Park JB, et al. A prospective longitudinal study evaluating the usefulness of a T-cell-based assay for latent tuberculosis
infection in kidney transplant recipients. Am J Transplant 2011;11:1927–35.
. Singh JA, Saag KG, Bridges SL, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol 2016;68:1–26.
. Aguado JM, Torre-Cisneros J, Fortún J, et al. Tuberculosis
in solid-organ transplant recipients: consensus statement of the group for the study of infection in transplant recipients (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology. Clin Infect Dis 2009;48:1276–84.
. Costa SD, de Sandes-Freitas TV, Jacinto CN, et al. Tuberculosis
after kidney transplantation
is associated with significantly impaired allograft function. Transpl Infect Dis 2017;19:e12750.
. Eastwood JB, Corbishley CM, Grange JM. Tuberculosis
and the kidney. J Am Soc Nephrol 2001;12:1307–14.