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Post transplant infections: Challenge in developing countries

Post transplant infections: Challenge in developing countries. Sindh Institute of Urology and Transplantation (SIUT) Karachi, Pakistan. Dance of death. Introduction. Infections have played an important role in the history of mankind

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Post transplant infections: Challenge in developing countries

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  1. Post transplant infections: Challenge in developing countries Sindh Institute of Urology and Transplantation (SIUT) Karachi, Pakistan

  2. Dance of death Introduction • Infections have played an important role in the history of mankind • Terrifying cartoons and paintings depict the killing fields of infections

  3. 50 million people died in the great plaguenearly 50% population of Europe

  4. Death due to infections Developing world Developed world 32 deaths / 100,000 307 deaths / 100,000 http://who.int/mediacentre/factsheets/fs310/en/index1.html

  5. Overall infections in Renal Transplantation Percent Linhares et al, Transplant Proc, 2004, Kee etal, Transplant Proc, 2004 Ko et al, Transplant Proc, 1994, Charfeddine et al, SJKD, 2002, Rizvi et al Kidney International, 2002, Transplantation 2013, SJKDT 2005, NDT 2010

  6. Transplantation at SIUT SIUT’s Healthcare Model Community – Government Partnership Dialysis Community Government Patient Transplantation Doctor Fully Integrated Renal Support Programme • Free with dignity with life long follow-up of recipients and donors with medications

  7. Haemodialysis centre at SIUT Sessions • 135 machines • 750 dialysis/day • 27% dialysis of entire country

  8. SIUT – largest kidney transplant centre in the region in last 27 years – 4140 transplants No. of Transplants 13

  9. Graft survival at SIUTComparison with Collaborative Transplant Study TR = Turkey IR = Iran IND = India Karachi = SIUT SIUT vs other regional countries SIUT vs CTS

  10. Looking for the factors that may result in lower outcome • Infection • Immunosuppression • Rejection

  11. Cause of death within first year post transplant TR = Turkey IR = Iran IND = India Karachi = SIUT

  12. Post Transplant infections (1985 – 2013)n = 4000In a follow-up period of 1 to 26 years Infection 67.3% 15% patients have recurrent infection

  13. Overall Pattern of Organisms causing infections Fungal Parasitic Bacterial 5% 12% 44% 39% Viral

  14. An overview of major infections

  15. Bacterial Infectionsn = 1875 (44%) • UTI constituted 79% of these infections and almost a quarter caused bacteremia Pyelonephritis Nocardia MRSA Pneumonia

  16. Miliary TB Post Transplant Tuberculosis 492 (12.3%) Sites of PTTB • Pulmonary 40% • Extra Pulmonary 44% • Disseminated 4% • Unknown 12% Laryngeal TB TB in Bone Presentation: Fever 96%, cough 56%, weight loss 31% Extra pulmonary sites: Lymph node, Intestines, Urinary Tract , Bone / joint, CNS

  17. CMV disease was the most common in 987 (60%) 54% of infections occurred between 2 -6 months Dengue 107 (6%) CMV Colitis Viral infection1633 (39%) CMV Colitis CMV Retinitis Viral warts Polyoma Varicella Herpes

  18. Norwegian Scabies Parasitic Infections491 (12%) • Malaria 41% of total parasitic infection Giardia lamblia Ameoba Malaria Toxoplasmosis

  19. Aspergillosis in graft Fungal Infections225 (5.6%) Cryptococcus • Candida 44%, Aspergillosis 32% of all fungal infections Candida Mucormycosis

  20. In some situations graft nephrectomy is the only option to save life Aspergillosis Mucormycosis Pyelonephritis

  21. Risk factors for infections in developing countries

  22. Causative Factors Pakistan Scenario Human development parameters • Access to safe water 47% • Unsafe sewage drainage 56% • Immunization 1 in 5 child • Malnutrition 40% Transplant specific • Rejection • Immunosuppression

  23. Impact of malnutrition on infection ratesSerum Albumin as a marker of nutritional status Infection Serum Albumin levels (mg/dl) Hypoalbuminemia Normal (< 3.50) (> 3.5) CMV 57% 43% TB 60% 40% UTI 63% 37% BK 57% 43% Fungal 66% 34% Overall > 60% have low albumin levels

  24. Impact of rejections on infection rates Rejection Group No Rejection Group Infections 84% P = 0.0001 Infections 58% • 70% rejections within 3 months 90% within 6 months • Anti-rejection therapy Steroids ± ATG

  25. Impact of induction by biological agents on infection rates Induction Group No Induction Group Infections 80% P = 0.0001 Infections 61% Induction by ATG, OKT3, IL-2 antagonist

  26. Causes of Patient and Graft LossFollow-up 1 to 27 yearsn = 4000 Graft n = 843 Patient n = 441 ACR 13% IFTA 54% Others 11% Cancer 1% Death with function Infection Infection 73% 28% CVD 15% UTI Recurrence of disease 5%

  27. Infection Control • Universal prophylaxis • Pre-transplant screening of donors and recipients • Avoidance of use of blood products • Treatment of pre-existing infections • Immunoprophylaxis vaccination • Continue after transplant with tailored chemoprophylaxis and surveillance • Reduction in the intensity of immunosuppression Adopted from Recommendations by Jay Fishman

  28. Investment in technology to diagnose infections Viral loads & genotype by PCR Serological markers for viral infection CMV antigen assay Routine cultures Fungal culture lab Molecular diagnostics TB

  29. Graft survival in three eras at SIUT Era 3 Era 2 Era 1 5 yr survival – 87% 5 yr survival – 76% 5 yr survival – 83% CTS vs SIUT SIUT data Impact of infection control and investment in technology

  30. However environment is different outside SIUT Wards > 50% live below the poverty line

  31. To transplant or not to transplant…….That is the question ?

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