Póvoas Diana, Machado João, Perdigoto Rui, Morbey Ana, Veloso Júlio, Glória Helena, Mateus Élia, Martins Américo, Maltez Fernando, Barroso Eduardo
Serviço de Doenças Infecciosas. Hospital de Curry Cabral. Lisboa. Portugal.
Serviço de Doenças Infecciosas. Hospital de Curry Cabral. Lisboa. Portugal; Centro Hepato-Bilio-Pancreático e Transplantação. Hospital de Curry Cabral. Lisboa. Portugal.
Acta Med Port. 2017 Jan 31;30(1):41-46. doi: 10.20344/amp.7052.
Tuberculosis incidence in Portugal ranged from 20 to 22 cases per 100 000 inhabitants between 2010 and 2014. Tuberculosis incidence in liver transplant recipients is not precisely known, but it is estimated to be higher than among the general population. Tuberculosis in liver transplant recipients is particularly challenging because of the atypical clinical presentation and side effects of the antibacillary drugs and their potential interactions with immunosuppressive therapies.
We retrospectively reviewed the clinical records of liver transplant recipients with post-transplant tuberculosis occurring from January 2010 to December 2014 at a liver transplantation unit in Lisbon, Portugal. Demographic data, baseline and clinical features, as well as treatment regimen, toxicities and outcomes, were analyzed.
Among 1005 recipients, active tuberculosis was diagnosed in eight patients between January 2010 and December 2014 (frequency = 0.8%). Late onset tuberculosis was more frequent than early tuberculosis. Mycobacterium tuberculosis complex was isolated from cultures in almost every case (7; 87.5%). Extra-pulmonary involvement and disseminated tuberculosis were frequent. Two patients developed rejection without allograft loss. Crude mortality was 37.5%, with 2 deaths being related to tuberculosis.
Despite the uncertainty regarding treatment duration in liver transplant recipients, disease severity, as well as number of active drugs against TB infection, should be taken into account. There was a need for a rifampin-free regimen and immunosuppression adjustment in patients who experienced acute graf rejection.
Although the number of cases of tuberculosis is low, its post-transplant frequency is significant and the observed mortality rate is not to be neglected. The cases of hepatotoxicity and graft rejection seen in this case series demonstrate the challenges associated with tuberculosis diagnosis in liver transplant recipients and management of the interactions between immunosuppressors and rifampin. This study strengthens the recommendation of latent tuberculosis infection screening and treatment in liver transplant candidates or recipients.
2010年至2014年间，葡萄牙的结核病发病率为每10万居民20至22例。肝移植受者的结核病发病率尚不清楚，但估计高于普通人群。肝移植受者的结核病尤其具有挑战性，因为其临床表现不典型，抗结核药物有副作用，且这些药物可能与免疫抑制疗法相互作用。
我们回顾性分析了2010年1月至2014年12月在葡萄牙里斯本一家肝移植单位发生移植后结核病的肝移植受者的临床记录。分析了人口统计学数据、基线和临床特征，以及治疗方案、毒性和结局。
在1005名受者中，2010年1月至2014年12月期间有8例患者被诊断为活动性结核病（发生率=0.8%）。迟发性结核病比早发性结核病更常见。几乎所有病例（7例；87.5%）的培养物中都分离出结核分枝杆菌复合群。肺外受累和播散性结核病很常见。两名患者发生排斥反应，但未出现移植物丢失。粗死亡率为37.5%，2例死亡与结核病有关。
尽管肝移植受者的治疗持续时间存在不确定性，但应考虑疾病严重程度以及抗结核感染的有效药物数量。对于发生急性移植排斥反应的患者，需要采用不含利福平的治疗方案并调整免疫抑制。
尽管结核病病例数较少，但其移植后的发生率较高，观察到的死亡率也不容忽视。本病例系列中出现的肝毒性和移植物排斥反应病例表明，肝移植受者的结核病诊断以及免疫抑制剂与利福平之间相互作用的管理存在挑战。本研究强化了对肝移植候选者或受者进行潜伏性结核感染筛查和治疗的建议。
