Bacille de Calmette et Guérin (BCG) vaccination is recommended for patients awaiting solid organ transplantation who are at risk of exposure to tuberculosis.1 However, avoidance of live vaccines within 4 weeks before transplantation is recommended.2 This situation is complicated by the fact that it is often difficult to avoid liver transplantation (LT) within this period because rapid deterioration of liver function may occur in infants, and the risk of BCG disease in these patients is still unknown. Moreover, the appropriateness of this time interval may not be applicable for BCG, given that Mycobacterium bovis may remain dormant and complications of BCG occur on average 13.9 months after vaccination.3
We identified 5 pediatric living donor LT recipients who received BCG vaccine within 4 weeks before LT (median, 22 days; 7-28) and 2 patients who received it after LT between January 2006 and October 2015. The reasons for requiring LT were to avoid crisis in patients with biliary atresia with severe liver failure (n = 3) or metabolic diseases (n = 2). No abnormal reaction at the site of BCG inoculation was observed at the time of LT. Initial immunosuppression after LT consisted of tacrolimus (TAC) and low-dose corticosteroids. The corticosteroids were tapered over 3 months. The average blood concentration of TAC in these patients was 4.5 and 3.8 after 6 months and 1 year, respectively. Two patients received high-dose methylprednisolone therapy to treat acute rejection, and 2 received mycophenolate mofetil and prednisolone. None of these patients required antithymocyte globulin therapy. Two patients received BCG vaccination inadvertently after LT at 28 and 29 months after LT from their primary care physician. No BCG disease was observed in any of these cases during the median (range) follow-up period of 80 (42-122) months. In addition, no BCG disease was observed in 144 patients who received BCG vaccination within 4 years to 4 weeks before LT, with an interval between BCG inoculation and LT of less than 3 months in 50 patients, 4 to 12 months in 54 patients, 13 to 24 months in 22 patients, and more than 25 months in 21 patients. One patient developed a BCG site subcutaneous abscess 1 month before LT but had an uneventful course after LT.
There are several potential explanations for the absence of BCG disease in these patients. The BCG Tokyo 172 strain used in Japan and some other Asian countries is associated with fewer side effects compared with other vaccine strains.4 Living donor LT, which is common in Japan, usually requires lower levels of immunosuppression to suppress rejection compared with deceased donor LT.5 The small number of subjects evaluated in our report limits the generalizability of our results, particularly outside Japan. However, we were able to document the lack of occurrence of BCG complications in a larger number of patients who received BCG vaccination within several years before LT. Our results suggest that prior receipt of BCG vaccination may not be a contraindication for LT.
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2. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis
3. Lin WL, Chiu NC, Lee PH, et al. Management of Bacillus Calmette-Guérin osteomyelitis/osteitis in immunocompetent children-A systematic review. Vaccine
4. Milstien JB, Gibson JJ. Quality control of BCG vaccine by WHO: a review of factors that may influence vaccine effectiveness and safety. Bull World Health Organ
5. Jain A, Venkataramanan R, Sharma R, et al. Pharmacokinetics of tacrolimus in living donor liver transplant and deceased donor liver transplant recipients. Transplantation