Departments of Nephrology, Pathology, and Biostatistics, Christian Medical College and Hospital, Vellore 632004, South India
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Infections are a major cause for mortality and morbidity in renal transplant recipients all over the world. In the tropics, infections account for the majority of deaths in the transplant population (1). Published accounts on the chronological appearance of various infections have helped physicians target investigative protocols and empirical treatment based on the probability of disease at varying intervals after transplantation. Risk of infection is determined by epidemiologic exposure to the infective agents and the net state of immunosuppression (2, 3). Even though the immunosuppressive protocols at this center are similar to those in the developed western countries, the added immunosuppression caused by concomitant infections, undernutrition, and organ dysfunction are different, as is the environmental exposure to various infective agents. The sequence of infections encountered after transplantation in this center is reported.From 1986 to 1994, 920 patients received living-related renal allografts. Low-dose prednisolone and azathioprine were employed initially, and cyclosporine-based immunosuppression was used since 1989 (4). Prednisolone-azathioprine-cyclosporine schedule consisted of oral prednisolone 20 mg/day from days 0 to 90. Azathioprine 1-1.5 mg/kg from days 0-5 was adjusted as per leukocyte response. Oral cyclosporine was initiated at a dose of 8 mg/kg on day 0 and tapered to 2 mg/kg by the 180th day. For the prednisolone-cyclosporine group 20 mg of prednisolone was given from days 0 to 90. Then it was tapered to a maintenance dose of 10 mg by the 180th day. Oral cyclosporine was initiated at 12 mg/kg on day 0 and reduced to 10 mg/kg by day 15. It was tapered to 3 mg/kg by the 180th day. Cyclosporine doses were modified as per cyclosporine blood levels (whole blood Enzyme Immuno Assay Syva, San Jose, Ca) in association with clinical features.The conventional immunosuppression consisted of azathioprine 2-2.5 mg/kg/day started on days 0-5 and modified by leukocyte response; 100 mg of prednisolone was started on day 0, reduced to 20 mg/day by the 28th day, and tapered to 10 mg by the 180th day.Acute rejections were treated with i.v. methylprednisolone 1 g on 3 consecutive days. Acute vascular rejections in patients receiving conventional therapy were treated with cyclosporine (5). Cyclosporine was added at a dose of 5 mg/kg/day, reduced to 4 mg/kg/day by 4 weeks and 3 mg/kg/day by 8 weeks.All patients were seen frequently for the first 6 months, then at the 9th month and 12th month. Thereafter, yearly followup was advised with earlier visits in case of complications. Our patients originate from all the states of India and neighboring countries like Nepal, Bhutan, Bangladesh, and Srilanka. Because communications were difficult and distances vast, all our transplant recipients stayed at Vellore for 6 months after surgery. Our policy was to discontinue cyclosporine at the end of 1 year. Hence, the followup at 6 months was 100%, 9th month about 80%, and 12th month 95%. Subsequent followup falls to about 40%; however, patients communicate with us or come to the center in case of major medical problems. Patients with fever of unknown origin or features of organ involvement had appropriate tests. The transplant-disease interval in 9 important infective syndromes is presented in Table 1 and charted (Fig. 1).Rubin categorized infections as those occurring within 1 month, 2-6 months, and thereafter. The first group included urinary infections, vascular access, catheter, and surgery related infections. In our patients also, urinary tract infections clustered around the first month, which was free from opportunistic infections. Pneumocystis carinii pneumonia was first seen in 1991 (6).