Authors' reply

P Sreejith, V Jha, HS Kohli, M Rathi, KL Gupta, V Sakhuja
Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh-160 012, India

Correspondence Address:
V Sakhuja
Department of Nephrology, Postgraduate Institute of Medical Education & Research, Chandigarh-160 012
India

Source of Support: None, Conflict of Interest: None

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PMID: 21206693

1. The KDIGO clinical practice guidelines for the care of kidney transplant recipients ^[3] recommend susceptibility testing on all isolates of Mycobacterium tuberculosis from kidney transplant recipients because the recipients may belong to diverse geographic locations where the prevalence of drug resistance may vary. Identifying drug susceptibility is all the more important in transplant recipients in view of the limited drug options available for them due to significant interaction of rifamycins with calcinurin inhibitors (CNIs) and mTOR inhibitors.The current recommendation for treatment of tuberculosis in kidney transplant recipient is to use the same treatment regimen as used in local general population who require therapy. ^[3] Rifampicin may be substituted with rifabutin with close monitoring of CNI drug levels, or a fluoroquinolone may be used instead of rifamycins. The efficacy of rifamycin sparing regimen in kidney transplant recipients has been reported from our center in the past. ^[4],[5] The duration of therapy has not been defined, but it may be prudent to consider the experience from rifampicin-free regimen used in general population, which in general are 9 months or more in duration.
2. Aguado et al. ^[6] has reported that treatment duration less than 9 months was associated with greater mortality, and Park et al. ^[7] reported that the only factor that was significantly associated with greater recurrence of TB was duration of treatment: no recurrence was observed in patients who received more than 12 months treatment, irrespective of whether the treatment regimen included rifampicin. The Spanish Society of Infectious Disease and Clinical Microbiology recommends ^[8] duration of at least 12-18 months in solid organ transplant recipients.
3. The prostatic abscess in our patient was asymptomatic and was picked up only on imaging; he had no evidence of bladder outlet obstruction. Hence, an intervention for draining the same was not considered necessary. A repeat CT scan after 3 months of antitubercular chemotherapy showed complete resolution of the abscess.

References

1.	Kalita P, Phukan C, Ali S. Tuberculosis in renal transplant recipient. Indian J Nephrol in press.
2.	Sreejith P, Jha V, Kohli HS, Rathi M, Gupta KL, Sakhuja V. Allograft and prostatic involvement in a renal transplant recipient with disseminated tuberculosis. Indian J Nephrol 2010;20:40-2.   [PUBMED]
3.	Kidney Disease: Improving Global Outcomes (KDIGO) Transplant work group. The KDIGO clinical practice guidelines for the care of kidney transplant recipients. Am J Transplant 2009;9:8.
4.	Sakhuja V, Jha V, Varma PP, Joshi K, Chugh KS. The high incidence of tuberculosis among renal transplant recipients in India. Transplantation 1996;61:211-5.   [PUBMED]  [FULLTEXT]
5.	Jha V, Sakhuja V, Gupta D, Krishna VS, Chakrabarti A, Joshi K, et al. Successful management of pulmonary tuberculosis in renal allograft recipients in a single center. Kidney Int 1999;56:1944-50.   [PUBMED]  [FULLTEXT]
6.	Aguado JM, Herrero JA, Gavaldα J, Torre-Cisneros J, Blanes M, Rufν G, Moreno A, et al. Clinical presentation and outcome of tuberculosis in kidney, liver, and heart transplant recipients in Spain. Transplantation 1997;63:1278-86.
7.	Park YS, Choi JY, Cho CH, Chang KH, Song YG, Kim YS, et al. Clinical outcomes of tuberculosis in renal transplant recipients. Yonsei Med J 2004;45:865-72.   [PUBMED]  [FULLTEXT]
8.	Aguado JM, Torre-Cisneros J, Fortϊn J, Benito N, Meije Y, Doblas A, et al. Tuberculosis in Solid-Organ Transplant Recipients: Consensus Statement of the Group for the Study of Infection in Transplant Recipients (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology. Clin Infect Dis 2009;48:1276-84.

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