Demir Erol, Sever Mehmet Sukru
Department of Nephrology, İstanbul School of Medicine, Millet Caddesi, Çapa, İstanbul, Turkey.
Exp Clin Transplant. 2017 Feb;15(Suppl 1):10-15. doi: 10.6002/ect.mesot2016.L32.
Tuberculosis is a major problem in the posttransplantation period, because of its high incidence and prevalence, difficulty in diagnosis as well as high risk of morbidity and mortality. In solid-organ transplant recipients, the diagnosis of tuberculosis is complex because it is paucisymptomatic. Tuberculin skin testing results may be negative, and interferon-gamma release assays may be insufficiently sensitive. Furthermore, imaging technique findings are mostly atypical, and sputum smear results can be negative despite the presence of active disease. Therefore, most tuberculosis cases are overlooked, and thus, treatment initiation is often delayed. The treatment of tuberculosis falls under 2 headings: that of active disease and latent disease. The drugs for treating these 2 entities are similar; however, their protocols are completely different. Active disease in the immunocompetent patient is treated mostly by giving isoniazid, rifampicin, pyrazinamide, and ethambutol for 2 months (intensive phase), followed by isoniazid and rifampicin for 4 months (continuation phase). The treatment of immunosuppressed patients is controversial; a similar protocol or longer duration of treatment has been suggested as compared to immunocompetent patients. Because there is a drug interaction between antituberculosis drugs (rifamycins) and immunosuppressants (calcineurin/mammalian target of rapamycin inhibitors and glucocorticoids), the risk of graft rejection increases during the treatment of tuberculosis. For the treatment of latent tuberculosis, in regions with a high prevalence of tuberculosis, universal prophylaxis with isoniazid for 6 months (preferably 9 months) has been recommended. In countries where the risk of tuberculosis is lower, no prophylaxis has been proposed. We propose that the best solution is to individualize therapy for patients at greatest risk of the disease. To conclude, posttransplant tuberculosis is still an important source of comorbidity in transplant recipients because of its high frequency, problems in diagnosis and treatment and association with increased risk of morbidity and mortality.
结核病是移植后时期的一个主要问题，因其发病率和患病率高、诊断困难以及发病和死亡风险高。在实体器官移植受者中，结核病的诊断很复杂，因为其症状较少。结核菌素皮肤试验结果可能为阴性，且干扰素-γ释放试验的敏感性可能不足。此外，影像学检查结果大多不典型，即使存在活动性疾病，痰涂片结果也可能为阴性。因此，大多数结核病例被忽视，治疗开始时间往往延迟。结核病的治疗分为两类：活动性疾病和潜伏性疾病的治疗。治疗这两种情况的药物相似；然而，它们的治疗方案完全不同。免疫功能正常的患者的活动性疾病主要通过给予异烟肼、利福平、吡嗪酰胺和乙胺丁醇治疗2个月（强化期），随后给予异烟肼和利福平治疗4个月（持续期）。免疫抑制患者的治疗存在争议；与免疫功能正常的患者相比，有人建议采用类似的方案或更长的治疗时间。由于抗结核药物（利福霉素）与免疫抑制剂（钙调神经磷酸酶/雷帕霉素哺乳动物靶点抑制剂和糖皮质激素）之间存在药物相互作用，在结核病治疗期间移植排斥反应的风险会增加。对于潜伏性结核病的治疗，在结核病高流行地区，建议普遍使用异烟肼进行6个月（最好9个月）的预防。在结核病风险较低的国家，未建议进行预防。我们建议，最佳解决方案是对疾病风险最高的患者进行个体化治疗。总之，移植后结核病仍然是移植受者合并症的一个重要来源，因为其发病率高、诊断和治疗存在问题以及与发病和死亡风险增加相关。
