Infektionen nach Nierentransplantation im Kindesalter

Zusammenfassung

Infektionen sind relevante Morbiditäts- und Mortalitätsfaktoren für Patienten nach einer erfolgreichen Organtrans-plantation. Aufgrund der immunsuppressiven Therapie ergibt sich eine höhere Empfänglichkeit für Infektionen gegenüber anderen pädiatrischen Patienten. Dazu steigt die Gefahr eines schweren Verlaufes inklusive Sepsis und Multiorganversagen bis zum Tod. Speziell nach Nierentrans-plantation sind febrile und afebrile Harnwegsinfektionen eine ernstzunehmende Komplikation, die Symptome einer Urosepsis aufweisen und zur akuten Transplantatdysfunktion führen können. Ansonsten spielen neben den im Kindesalter häufigen bakteriellen und viralen Infektionen des Respirationstraktes sowie Virusgastroenteritiden insbesondere Infektionen durch Viren wie CMV, EBV, Herpes-simplex-Virus und Polyomaviren eine relevante Rolle. Opportunistische Infektionen durch Pilze oder Pneumocystis carinii sind zwar selten, müssen aber wegen ihrer schlechten Prognose differenzialdiagnostisch immer berücksichtigt werden. Ziel dieses Artikels ist es, die Differenzialdiagnostik der häufigsten Infektionen in den verschiedenen Phasen nach Nierentransplantation im Kindesalter zu erläutern und relevante Therapiemaßnahmen (symptomatische, Antibiotika) zu vermitteln.

summary

Infectious complications are the leading cause of morbidity and mortality after successful solid organ transplantation. Immunosuppression contributes not only to a higher susceptibility to infection in contrast to the general pediatric population but also to an increased risk of sepsis, organ failure and death. Signs and symptoms of infection may be diminished in immunocompromised hosts. Especially febrile and afebrile urinary tract infections are an important complication, which can result in urosepsis and allograft dysfunction. Viral respiratory tract infections and gastroenteritis are the most frequent types of infection encountered after organ transplantation. Other important infectious complications are due to CMV, EBV and polyomavirus. Opportunistic and fungal pathogens have to be considered and may have a poor prognosis. General concepts in differential diagnosis and treatment after renal transplantation as well as prophylactic measures in pediatric patients after kidney transplantation will be discussed.

Schlüsselwörter

Nierentransplantation - Infektion - Harnwegsinfektion - Immunsuppression

Keywords

Renal transplantation - infection - urinary tract infection - immunsuppression

• Literatur

• 1 Abbott KC, Swanson SJ, Richter ER. et al. Late urinary tract infection after renal transplantation in the United States. Am J Kidney Dis 2004; 44 (Suppl. 02) 353-362.
• 2 Bakir N, Surachno S, Sluiter WJ, Struijk DG. Peritonitis in peritoneal dialysis patients after renal transplantation. Nephrol Dial Transplant 1998; 13 (Suppl. 12) 3178-3183.
• 3 Benfield MR. Current status of kidney transplant: update 2003. Pediatr Clin North Am 2003; 50 (Suppl. 06) 1301-1334.
• 4 Caillard S, Agodoa LY, Bohen EM, Abbott KC. Myeloma, Hodgkin disease, and lymphoid leukemia after renal transplantation: characteristics, risk factors and prognosis. Transplantation 2006; 81 (Suppl. 06) 888-895.
• 5 Chavers BM, Gillingham KJ, Matas AJ. Complications by age in primary pediatric renal transplant recipients. Pediatr Nephrol 1997; 11 (Suppl. 04) 399-403.
• 6 Chavers BM, Solid CA, Gilbertson DT, Collins AJ. Infection-related hospitalization rates in pediatric versus adult patients with end-stage renal disease in the United States. J Am Soc Nephrol 2007; 18 (Suppl. 03) 952-959.
• 7 Choquet S, Leblond V, Herbrecht R. et al. Efficacy and safety of rituximab in B-cell post-transplantation lymphoproliferative disorders: results of a prospective multicenter phase 2 study. Blood 2006; 107 (Suppl. 08) 3053-3057.
• 8 Dharnidharka VR, Caillard S, Agodoa LY, Abbott KC. Infection frequency and profile in different age groups of kidney transplant recipients. Transplantation 2006; 81 (Suppl. 12) 1662-1667.
• 9 Drachenberg RC, Drachenberg CB, Papadimitriou JC. et al. Morphological spectrum of polyoma virus disease in renal allografts: diagnostic accuracy of urine cytology. Am J Transplant 2001; 1 (Suppl. 04) 373-381.
• 10 Fishman JA. Infection in solid-organ transplant recipients. N Engl J Med 2007; 357 (Suppl. 25) 2601-2614.
• 11 Green M, Webber S. Posttransplantation lymphoproliferative disorders. Pediatr Clin North Am 2003; 50 (Suppl. 06) 1471-1491.
• 12 Hirsch HH, Suthanthiran M. The natural history, risk factors and outcomes of polyomavirus BK-associated nephropathy after renal transplantation. Nat Clin Pract Nephrol 2006; 2 (Suppl. 05) 240-241.
• 13 John U, Everding AS, Kuwertz-Broking E. et al. High prevalence of febrile urinary tract infections after paediatric renal transplantation. Nephrol Dial Transplant 2006; 21 (Suppl. 11) 3269-3274.
• 14 John U, Kemper MJ. Harnwegsinfektionen nach Nierentransplantation. Mschr Kinderheilkd 2007; 155: 234-241.
• 15 Kalil AC, Levitsky J, Lyden E, Stoner J, Freifeld AG. Meta-analysis: the efficacy of strategies to prevent organ disease by cytomegalovirus in solid organ transplant recipients. Ann Intern Med 2005; 143 (Suppl. 12) 870-880.
• 16 Kemper MJ, Laube G, Blasius M, Neuhaus TJ. The child with initially refractory skin infection after renal transplantation. Nephrol Dial Transplant 2002; 17 (Suppl. 05) 927-928.
• 17 Kuypers DR, Vandooren AK, Lerut E. et al. Adjuvant low-dose cidofovir therapy for BK polyomavirus interstitial nephritis in renal transplant recipients. Am J Transplant 2005; 5 (Suppl. 08) 1997-2004.
• 18 Opelz G, Daniel V, Naujokat C, Fickenscher H, Dohler B. Effect of cytomegalovirus prophylaxis with immunoglobulin or with antiviral drugs on post-transplant non-Hodgkin lymphoma: a multicentre retrospective analysis. Lancet Oncol 2007; 8 (Suppl. 03) 212-218.
• 19 Rubin RH. Infectious disease complications of renal transplantation. Kidney Int 1993; 44 (Suppl. 01) 221-236.
• 20 Rubin RH, Tolkoff-Rubin NE. Viral infection in the renal transplant patient. Proc Eur Dial Transplant Assoc 1983; 19: 513-526.
• 21 Sagedal S, Rollag H, Hartmann A. Cytomegalovirus infection in renal transplant recipients is associated with impaired survival irrespective of expected mortality risk. Clin Transplant 2007; 21 (Suppl. 03) 309-313.
• 22 Shroff R, Rees L. The post-transplant lymphoproliferative disorder −a literature review. Pediatr Nephrol 2004; 19 (Suppl. 04) 369-377.
• 23 Srinivasan A, Burton EC, Kuehnert MJ. et al. Transmission of rabies virus from an organ donor to four transplant recipients. N Engl J Med 2005; 352 (Suppl. 11) 1103-1111.
• 24 Strippoli GF, Hodson EM, Jones CJ, Craig JC. Pre-emptive treatment for cytomegalovirus viraemia to prevent cytomegalovirus disease in solid organ transplant recipients.. Cochrane Database Syst Rev. 2006 (1) CD005133.
• 25 Their M, Holmberg C, Lautenschlager I. et al. Infections in pediatric kidney and liver transplant patients after perioperative hospitalization. Transplantation 2000; 69 (Suppl. 08) 1617-1623.