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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2002  |  Volume : 13  |  Issue : 2  |  Page : 195-198
Infection in Kidney Transplant Recipients in Tunisia

Department of Nephrology and Renal Transplantation, University-Hospital, Sfax, Tunisia

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To determine the patterns of infectious complications in the renal transplant recipients in our center, we evaluated 18 patients (13 males and five females) who were transplanted between 1994-1998. The average age of the patients was 28 years. Sixteen (88%) and 2 (12%) transplants were from living-related and cadaver donors, respectively. Posttransplant immunosuppression consisted of azathioprine, prednisone, antithymocyte globulin (ATG) and cyclosporine.The acute rejection episodes were treated with pulse doses of methylprednisolone; steroid resistant rejection was treated with ATG or muromonab (OKT3). All patients received prophylaxis with sulfadoxin-pyrimethamine; none received prophylaxis against cytomegalovirus (CMV) infection. Thirteen (72%) recipients developed 44 confirmed episodes of infection; 19 (43%) episodes occurred in the early postoperative period, 16 (36%) in the first month and nine (20%) after six months. According to the type of infection, there were 12 urinary tract, 12 CMV, four herpal, five general septic, three fungal, two pneumonia, one disseminated nocardial and five miscellaneous episodes. All six (100%) patients who had acute rejection episodes developed infection compared with 7/12 (58%) who did not have rejection (p < 0.01). There was a significant correlation between CMV disease and acute rejection. CMV infection occurred after the additional immunosuppressive treatment for acute rejection in 6/6 (100%) patients. We conclude that CMV infection was the most frequent opportunistic pathogen in our renal transplant population and related to the intensive antirejection therapy, followed by urinary tract infection, which occurred within three months after surgery.

Keywords: Kidney transplantation, Infection, Cytomegalovirus, Urinary tract infection.

How to cite this article:
Charfeddine K, Kharrat M, Yaich S, Jarraya F, Mkawar K, Hachicha J. Infection in Kidney Transplant Recipients in Tunisia. Saudi J Kidney Dis Transpl 2002;13:195-8

How to cite this URL:
Charfeddine K, Kharrat M, Yaich S, Jarraya F, Mkawar K, Hachicha J. Infection in Kidney Transplant Recipients in Tunisia. Saudi J Kidney Dis Transpl [serial online] 2002 [cited 2022 Aug 12];13:195-8. Available from: https://www.sjkdt.org/text.asp?2002/13/2/195/33137

   Introduction Top

Although significant advances have been made in the surgical technique, the immuno­logic aspects and the immunosuppressive protocols of renal transplantation, infection continues to be a major problem. Nearly 80% of renal transplant recipients suffer at least one episode of infection during the first year after transplantation and infection remains the leading cause of morbidity and mortality throughout the post-transplant course. [1],[2]

Prevention and treatment of infection in the transplant recipient is of major importance, and the required immunosuppressive therapy must be judiciously administered. [3] Previous studies have shown that there is a typical timetable that characterizes the post-transplan­tation infection pattern; particular types of infection being more likely to occur at different time periods. [2],[4],[5] Accordingly, in the first month post-transplantation, opportunistic (fungal, nocardial and protozoal) infections are almost non-existent. Indeed, the major presentations of infection are the bacterial wound, pulmo­nary and urinary tract infections.

The greatest risk of life-threatening infection is in the time period one to six months post­transplantation, when the immunosuppres­sive effects of anti rejection therapy are at their peak. Cytomegalovirus is the most common opportunistic organism encountered at this time interval.

After six months of transplantation, the time when maintenance immunosuppressive therapy is at its lowest level, three types of infections are commonly observed. These include: chronic, particularly viral, infections, an occasional opportunistic infection and the usual infections prevailing in the general community such as influenza, pneumococcal pneumonia and urinary tract infection (UTI).

The purpose of this study was to determine the patterns of the prevalent infectious comp­lications in the renal transplant recipients in one transplant center in our country.

   Patients and Methods Top

Twenty-one patients who underwent kidney transplantation at Hedi Chaker University Hospital, Sfax-Tunisia from March 1994 to September 1998 were studied. Three patients were excluded from the analysis because of early loss of the graft. There were 18 patients, 13 males and five females with an age range of 10 to 38 years (average 28 years). The patients had an average duration of 42 months (range 6 to 58 months) on hemodialysis. Sixteen (88%) and 2 (12%) transplants were from living-related (LRDK) and cadaver donors, respectively.

The induction regimen of immunosup­pression in both cadaver kidney and LRDK transplantation consisted of azathioprine, prednisone, and antithymocyte globulin (ATG). After a short course of ATG, this was discontinued and the recipients were started on cyclosporine. Acute rejection episodes were treated with pulse doses of methyl­prednisolone. Steroid resistant rejections were diagnosed by transplant biopsies and treated with ATG for 10 to 14 days or muro­monab (OKT 3 ) for 10 days. All patients received sulfadoxin-pyrimethamine for pro­phylaxis against Pneumocystis carinii infection.

All recipients and donors were cytomegalo­virus (CMV) antibody seropositive and prophylaxis against the CMV infection was not administered. We divided the post­transplant follow-up into three periods: less than one month (perioperative period), from 1-6 months (early post operative period) and more than 6 months (late post-operative period).

During the posttransplant course, the patients were closely monitored for infections. Urine specimens for culture were obtained daily during the first week, twice a week for the next 4 weeks, once every month for the next 6 months and whenever indicated by the presence of unexplained fever or symp­toms suggestive of UTI. Any fever was investigated by clinical examination, chest X-Ray, urine and blood cultures and ultra­sound examination of the renal graft. CMV disease was diagnosed by the acute rise of antibody titer.

   Statistical Analysis Top

The incidence of infection was analyzed with regard to the sex, duration of hemodialysis period, source of kidney and acute rejection episodes. Patterns of infection were further categorized with regard to the time interval after transplantation, the causative organisms and the site of infection. Results were analyzed using the Fisher and student tests.

   Results Top

Thirteen (72%) of the 18 renal allograft recipients developed 44 episodes of infection during the three periods after transplan­tation. Sixteen (36%) episodes occurred in the first 30 days, 19 (43%) in the early post­transplant period and nine (20%) in the late post transplant period.

There were 12 episodes of UTI, 12 of CMV-disease successfully treated by gan­ciclovir, four of human herpes virus diseases, five of sepsis, three of fungal infection, two of pneumonia, one of disseminated nocardosis caused by  Nocardia farcinica Scientific Name Search  and five of miscellaneous infections. The causative organisms were bacterial in 25 (55%), viral in 16 (36%) and fungal in 3 (7%) infections. Twelve of the sixteen viral infections were caused by CMV, eight of which (65%) occurred within six months after surgery [Table - 1], and six of the 12 patients with CMV disease received methylprednisolone pulse therapy and/or ATG.

The incidence of infection did not differ significantly between males and females (72% versus 60%) or donor type (75% living related versus 50% cadaver). All the six patients (100%) who had acute rejection episodes developed infections compared to 7 of 12 (58%) who did not have rejection (p < 0.01). There was a significant correlation between CMV disease and acute rejection. CMV disease occurred after the additional immunosuppressive treatment for acute rejection in those six patients.

The actuarial patient survival rates at one and two years were 91% and 84% in recipients with infection and 100% in recipients without infection, respectively. The actuarial graft survival rates were 90% and 79% in recipients with infection and 92% and 78% in recipients without infection, respectively (the difference was not significant). We found no death directly attributable to infection episode in our patients after renal transplantation.

   Discussion Top

This study demonstrates that CMV and UTI were the most common infections after transplantation in our population.

In fact, CMV is the most frequently occurring opportunistic pathogen in the kidney transplant patients, and it generally occurs in the first six months after transplantation. [5] In our series, all CMV presentations were tissue-invasive disease. We found no death directly attributable to CMV disease and all patients who had it were treated successfully with ganciclovir.

In our study, all kidney donors and recipients were CMV antibody seropositive. CMV seronegative (R-) and/or seropositive (R+) kidney recipients of a transplant from a seropositive donor (D+) are especially at risk for CMV infections. [2],[6],[7],[8] Acyclovir at high doses (800 mg four times daily) or oral ganciclovir administered for three months after transplantation decreases the incidence of CMV-diseases when compared to placebo regardless of serologic status including the "high risk" group (D+/R-). [8]

In our study and other published reports [2],[6] there was a significant correlation between CMV disease and acute rejection episode. The cumulative immunosuppressive effects during the anti-rejection therapy increase the risk of CMV infection [2],[8] which may be reduced by the use of prophylactic acyclovir or ganciclovir.

As in previously reported series, [1],[2],[5],[8],[9],[10] UTI was the most common form of bacterial infection in our renal transplant recipients.

UTI occurs in 35% to 80% of renal transplant recipients. [3] There is a general agreement that UTI beginning six or more months post-transplant is rather benign and has an excellent prognosis. In contrast, UTI appearing in the first three months is frequently associated with overt pyeloneph­ritis, bacteremia and allograft dysfunction. In our series, nine out of 12 UTI occurred within the first three months after surgery. They, however, had a benign course. We were not able to find a significant correlation between UTI and rejection in our cases.

Renal transplant recipients with severe infection have usually inferior graft survival rates compared to those without infection. Graft loss is usually secondary to the tendency to decrease immunosuppression dose during the active infection. [1] In our series, the infection did not affect the short­term graft survival.

We conclude that CMV was the most frequent opportunistic pathogen in our renal transplant population and the infection was usually related to the intensive antirejection therapy. UTI was the next common infection, and tended to occur within three months after surgery.

   References Top

1.Kumar MS, Cridge P, Molavi A, Stephan R, Abouna GM. Infectious complications in the first 100 days after renal transplantation. Transplant Proc 1995;27(5):2705-6.  Back to cited text no. 1    
2.Rubin RH, Wolfson JS, Cosimi AB, Tolkoff­Rubin NE. Infection in the renal transplant recipient. Am J Med 1981;70:405-11.  Back to cited text no. 2  [PUBMED]  
3.Tanabe K, Takahashi K, Tokumoto T, et al. Infectious complications in ABO-incom­patible living donor kidney transplantation: a single center experience. Transplant Proc 1998;30:3130-2.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Tolkoff-Rubin NE, Rubin RH. Chronologie des infections et infections virales chez les transplantes d'organes: une vue d'ensemble. In: Herve P, Rifle G, (eds). Transplantation d'organes et greffe de tissus. Paris: les editions INSERM 1994:443-58.  Back to cited text no. 4    
5.Snydman DR. Infection in solid organ trans­plantation. Transpl Infect Dis 1999;1(1):21-8.  Back to cited text no. 5    
6.Tomikawa S, Ichikawa N, Kikuchi K, et al. Major infectious complications as a risk factor in kidney transplantation. Transplant Proc 1998;30:3127-9.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Tolkoff-Rubin NE, Rubin RH. Viral infections in organ transplantation. Transplant Proc 1998;30:2060-3.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Villacian JS, Paya CV. Prevention of infections in solid organ transplant recipients. Transplant Infect Dis 1999;1(1):50-64.  Back to cited text no. 8    
9.Takai K, Aoki A, Suga A, et al. Urinary tract infections following renal transplan­tation. Transplant Proc 1998;30:3140-1.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Cuvelier R, Pirson Y, Alexandre GP, Van Ypersele de Strihou C. Late urinary tract infection after transplantation: prevalence, predisposition and morbidity. Nephron 1985; 40:76-8.  Back to cited text no. 10  [PUBMED]  

Correspondence Address:
Khaled Charfeddine
Professor of Nephrology, Sfax University, P.O. Box 288,3027, Sfax-Jadida
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Source of Support: None, Conflict of Interest: None

PMID: 17660663

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