European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV.7.2. Late infections. Tuberculosis.

A. Tuberculosis (TB) is not rare after renal transplantation, and can be life-threatening. Treatment of active TB in renal transplant recipients should be the same as in the general population, i.e. 2 months of quadruple therapy combining rifampin, isoniazid, ethambutol and pyrazinamide, followed by a 4-months double therapy with isoniazid and rifampin. The drug ethambutol should not be used initially if the rate of resistance to isoniazid is less than 4% in the community. B. As rifampin will reduce the plasma concentration of calcineurin antagonists and rapamycin, the blood levels of these agents must be monitored closely. Rifabutin may be used as an alternative to rifampin, as this drug is a less potent inducer of the microsomal P450 enzymes. C. Renal transplant candidates and renal transplant recipients should be screened for latent TB infection. Patients considered to have latent TB infection are defined as: (i) those who display a 5 mm (renal transplant recipients) or a 10 mm (dialysis patients) induration after tuberculin skin testing; (ii) those with chest X-ray images suggestive of past TB infection; (iii) those with a history of past TB infection that was not treated adequately; and (iv) those who have been in close contact with infectious patients. The preferred treatment of latent TB infection is isoniazid 300 mg/day for 9 months.