Post Renal Transplant Infections: A Six Month Follow-Up Study from a Kidney Transplant Institute of North India

: Transplantation returns the majority of patients to an improved life-style and an improved life expectancy, as compared to patients on dialysis. Infections are the most prevalent cause of morbidity and mortality in kidney transplant recipients, with more than 80% suffering at least one episode of infection in the first year. The method of data collection in this study was prospective hospital record analysis, all renal transplant recipients were screened pre operatively for the presence of any overt or occult infection. The predominant age group undergoing renal transplantation was between 18 - 29 yrs. Urinary tract infections were the highest and commonest infections observed. The microorganisms involved in the infections were Bacteria (36.4%), Viruses (7.6%), Fungi (3.7%) and Parasites (5.5%). In Urinary tract infection, E. coli followed by Klebsiella pneumoniae were the predominant bacterial isolates. Candida albicans were the commonest fungi isolated. Among the Gastrointestinal tract infections, Cryptosporodium was the commonest Protozoal isolate. Cryptococcus neoformans was isolated in two cases of meningitis. In this study the organisms causing infection during the immediate operative period have been categorized, which will give the treating physician a reasonable idea to suspect the system and cause of infection during the particular post renal transplant period. This study has focused to evaluate the spectrum of infectious complications in post renal recipients in first 6 months of follow up and evaluate the most common type of infection.


INTRODUCTION
Kidney transplantation offers a healthier life over hemodialysis in patients with end-stage renal disease (ESRD). The survival following transplantation is determined by various factors, including pretransplant co-morbidities, graft type, and degree of immunosuppression (Arend et al., 1997). The new developed immunosuppressive drugs has lead to the reduction in mortality of renal transplant recipients (RTRs). Nevertheless, potent immunosuppression poses an extra risk of infectious disorders in the transplant recipients. One quarter of RTR develop a serious infection in the post-transplant period that causes allograft dysfunction (Ram et al., 2005). Bacterial infections are very frequent as compared to the viral infections in RTR. Nearly 13% of all patients transplanted between 1996 and 2000 in the US needed hospitalization for bacterial infections in the first 3 years compared to 6% for viral infections (Dharnidharka et al., 2007).
In the period from one to six months after transplantation, infections with immunomodulating viruses, particularly cytomegalovirus, are most important. Cytomegalovirus accounts for two-thirds of febrile episodes during this period. In addition to the clinical syndromes induced by these viruses, their immunomodulating properties predispose to opportunistic infections with such organisms as Pneumocystis carinii, Listeria monocytogenes, and Aspergillus fumigates (Pava, 1993;Fishman, 1995;Hadley and Karchmer, 1995;vanDenberg et al., 1996). Other infections generally occurring during this period include hepatitis, Herpes zoster, Herpes simplex, Mycobacterium tuberculosis, and Epstein-Barr virus (EBV), which can be complicated by the development of lymphoproliferative disorders. Recurrence or relapse of urinary tract infections can also occur (Fishman and Rubin, 1998). Most infections occur early in the post-transplantation course with about two-thirds of renal transplant recipients (RTR) experiencing an infectious-related complication in the first year after transplantation . Approximately 70% of severe bacterial, fungal and viral infections occur within 3 months of transplantation. This study has focused to evaluate the spectrum of infectious complications in post renal recipients in first 6 months of follow up and evaluate the most common type of infection.

Methodology
A. Collection of specimen. B. Microscopical examination. C. Culture procedure and identification of organisms.

Collection of specimens
Urine, Drain fluid, foley catheter tip and Drain tip were collected from all cases. According to signs and symptoms, Blood, Serum, Sputum, Oral scrapings, Faeces, Pus and CSF were collected.

OBSERVATION AND RESULTS
Infection in renal transplantation is a major and severe penalty of immunosuppression and is associated with high mortality. In order to prevent the occurrence of infection, one should know the commonest types of infection in that particular group of patients. Hence, a detailed account of post renal transplant infections was made to find out the present trend of infections and their incidence in renal transplant patients. All the details produced were based on the post renal transplant follow up of the patients which mainly explains the prevalence of infection, most common type of infection and most common organism involved.                  (Table-1). All 75 cases underwent live related donor transplantation and no case underwent Cadaver transplantation. Urinary tract infections were commonest followed by respiratory tract infections (Table-8). Bacterial infections were the most common infections in the post transplant period (Table-9).

URINARY TRACT INFECTION
Urinary tract infections (UTIs) are the most common bacterial infections requiring hospitalization in kidney transplant recipients, followed by pneumonia, postoperative infections, and septicemia. Women are at greatest risk for UTIs; other risk factors include deceased-donor transplant, kidney-pancreas transplantation with bladder drainage, prolonged catheterization, uretero-vesical stents, and increased immunosuppressed state (Lorenz EC and Cosio FG., 2010). 155 Urinary tract infections were the single most common infection occurring in renal transplant recipients, as noted in the present study and also reported by Rubin, et al., (1981) 141 and Jadav, et al., (1992). 142 Urinary tract infection constituted 54.5% (Table-8) of the total infections in this study. Umesh et al., (2007) has reported 31.1% of UTI incidence in transplant recipient. Jadav, et al., (1992) observed the incidence of 53% which were in congruence with the present study. Krieger JN, et al. [1977] observed 61% , the reports of Leigh, D.A. (1970) and Chan, P.C. (1990) varies from 30-79%, 31% incidences based on study by Chan PC, et al. [1990]. The incidences of 51% reported by Ravi kumar (1998) were in proximity with current investigation. A study of 28,942 primary renal transplant recipients from the U.S. has revealed a cumulative UTI incidence of 17% during the first 6 months after transplantation; at 3 years the incidence were 60% for women and 47% for men . Kumar Enterococcus faecalis. Similar organisms were also isolated by Paul, D. Ellner (1987). E. coli followed by Klebsiella pneumonia were the most frequently isolated organism in this study. Takai et al., (1998) found that E.coli was the commonest organism causing urinary tract infection. Gram negative bacilli of Enterobacteriaceae family were most frequently isolated in urinary tract infections in a study by Morz, E. et al., (1993). 3.3% of the urinary tract infections were due to fungi of which all were caused by Candida albicans. Funguria has been attributed in part to the widespread use of broad spectrum antibiotics, Corticosteroid, antineoplastic agents, immunosuppressive agents and urinary catheterization. Fluconazole is the drug of choice for susceptible Candida species; other azoles and echinocandins are not concentrated in the urinary tract and thus are less likely to be effective if infection is confined to the urinary tract (Pappas PG. et al., 2004;).

RESPIRATORY TRACT INFECTION
Respiratory tract infection occurred in 16.3% of the transplant recipient in comparison with 33% based on the study by the Jha R, et al. [1999].
Respiratory tract infection constituted about 14.5% of the total infections which was second most prevalent infection in the current study (Table-8). These reported incidence showed proximity with some of the previous studies whereas some reports showed a significant variation: 8% of incidences were observed by Moore, F.D et al., (1983), 15% by Giri (1992) which is approximately same as reported by present study, 12.6% by Ravi kumar (1998), 33% by Jha R, et al. [1999].  reported 8% of RTI incidences as second most prevalent infection in renal transplant patients following UTI. Organisms causing bacterial infection were E. coli, Gee-Chen Chang (2004) , mention which organism was involved in current study.

GASTROINTESTINAL TRACT INFECTION
Infections of the Gastrointestinal tract occurred in 12.7% of the total infectious patients (Table-8

SKIN AND SOFT TISSUE INFECTION
Skin and soft tissue infection accounted for 5.5 % of the infections (Table-10). Among the infections Staph aureus-1 Herpies-2 and Histoplasma-1.

CYTOMEGALO VIRAL INFECTION
Cytomegalovirus infection is a recognized problem of the early post transplant period in renal transplant recipients (Boehter A., 1994). In the present study, one patients (1.8%) developed cytomegalovirus infection which was detected in the first month of transplant (Table ). Kumar

CENTRAL NERVOUS SYSTEM INFECTION
Two patients were observed to develop meningitis which constituted 3.6% of the total infectious. Giri, (1992) has reported the incidence of 0.7% in his study. The causative organism was found to be Cryptococcus neoformans. Both patients developed meningitis in the 6th month post transplant. Ravi kumar (1998) has also repoted two cases of Cryptococcus neoformans meningitis in his study. It has been mentioned that Cryptococcus neoformans, the single most common cause of central nervous system infection in the renal transplant patients, occurs almost exclusively in the late post transplant period (more than six months after transplant ) Robert H. Rubin, (1993).