Spectrum of Infections in Renal Transplant Dr. Salil Jain Fortis Memorial Research Institute, Gurgaon

INTRODUCTION Transplantation Dialysis ESRD CKD CKD- an EPIDEMIC Prevalence- 1 in 10 Progressive disease ESRD 150,000- in India on waitlist for renal tx Renal tx- 1 out of 30 90%- on waiting list die without getting an organ Transplantation Dialysis ESRD CKD

COMPLICATIONS OF KIDNEY TRANSPLANT Rejection Infection Side effects of immunosupressants

Infections Rejection Immunosuppression

Infections Late presentation Endemic infections eg TB Expensive/nonavailability of lab tests Lack of awareness in primary care physicians Infections Socioeconomic status Poor hygiene New potent immunosupressives Tropical climate

Post Renal Tx -Infections Developed vs developing nations- different spectrum of infections Developing- 25% patients serious infection  allograft dysfunction Infections accounts for 50% deaths in India Common infections: UTI, TB, Candidiasis, Hepatitis B/C, CMV, Pneumocystis jirovecii

Aim & Objective To study the incidence of infections in post renal allograft recipient and influence of factors leading to infections To find out the most common cause of infections in post renal transplant patients To correlate the incidence of various infections with the literature

Materials and methods Single Centre observational retrospective hospital based study Inclusion Criteria: all of the following All patients who underwent renal transplant from September, 2013 to January, 2017 at FMRI Patients having regular follow up for at least 3 months post transplant in Outpatient clinic Exclusion criteria : Patients lost to follow up after first 3 months Definition of infection- culture/serology positive with suggestive symptoms

Results Baseline characteristics Variable n No of transplants 150 Males 124 Females 26 Mean age (years) 41.1 + 14.66 Dialysis vintage 7.38 months(15 days to 72 mnths) Primary diagnosis Hypertension Diabetes CGN Obstructive PKD CIN Unclassified 72 44 14 6 7 5 2

Results Baseline characteristics Variable n(%) Induction IL-2 50 (33.3%) ATG 91 (60.7%) No induction 9 (6%)

Patient distribution

Spectrum of positive cultures

Results- type of infection Infections Number of episodes UTI 48 GI infection 27 Pneumonia 11 Soft tissue infection 8 Fungal 3 TB 2 Parvovirus Herpes CMV

Spectrum of infection

Spectrum of bacterial infections E. coli 30(34%) Klebsiella 13(14.7%) Staphylococcus 10(11.3%) Pseudomonas 7(7.9%) Enterococcus Acinetobacter 4(4.5%)

Bacterial infections-spectrum

Infection Incidence of infection ATG 46% P = 0.69 IL-2 42.8% Diabetic 43.2% P= 0.98 Nondiabetic 43.3%

Kumar 2016 R Ram 2005 S Sujit 2016 FMRI No. of patients 45 169 50 150 Mean age (years) 35.5+10.4 34.1+11.4 - 41.1 Infection episodes After 1 year 57 77.7% 410 128 105 Induction, ATG vs IL-2 9.2 vs 6.8% NS UTI 33.3% 23.6% 72.7% 46.6% TB 17.8% 10.6% 1.9% Fungal 15.6% 23% 8% 2.9% CMV 13.3% 21.8% 7.8% HBV 11.1% 9.4% 3.9% HCV 7.6% Deaths 8.9% 2.4% 1.3% 10%

Discussion Overeall, infection incidence was lower compared to other studies in similar geographical region Lower rate of CMV due to universal prophylaxis Lower HBV/HCV due to stringent pretx workup and better medications for their tx. Fungal/CMV infections have come down considerably in last 10 years due to better prophylaxis and lesser immunosuppression.

Conclusion Infection still remains one of the most important complication and cause of mortality in transplant patients UTI continues to be the commonest post transplant infection We need investigations to monitor immune function to effectively manage immunosuppression Multicentric prospective studies needed to assess various factors associated with infection To increase the safety of organ transplantation further, we need improved diagnostic tests to detect infection earlier