Patient, male, 44 years old, with second kidney transplant, required special preparation
therapy, because he was sensitized, with concentration of Panel Reactive Antibody (PRA) class I 11% and PRA class II 76%. On the day of
transplantation, induction was done with
anti-thymocyte globulin (ATG) and glucocorticosteroids. After
transplantation,
plasmapheresis with ATG was performed. On the fourth day patient was anuric. Fine-needle biopsy of the graft was performed and showed positive CD4
antibodies for peritubular capillaries and humoral rejection. 14
plasmaphereses through 14 days, were negative and ATG treatment was suspended completely. Full therapeutic dosage of
tacrolimus and
mycophenolate mofetil were given during treatment. Four days
after treatment patient was stable, but next day clinical status had worsened with
dyspnea and
fever. In sputum, spores of Aspergillus species were microscopically found, and radiologically by computerised tomography.
Caspofungin was administered for seven days.
Voriconazole therapy was given for first ten days by intravenous route and after then orally. Even with this treatment, there was no improvement in clinical picture, while CT scan of the lungs showed
abscess collection in right lung. Lobectomy was performed and
pus collection was found. After graft-nephroctomy, patient was treated with continous veno-venous
hemodiafiltration (CV-VHDF) dialyses, with constant
voriconazole therapy for the next three months (200mg two times per day). After one month of diagnosis,
Galactomannan (GM) test was negative.
CONCLUSION: Although highly sensitized patients, those who are on
hemodialysis, in preparation for
transplantation, receive intensive immunosuppressive therapy that suppress the immune system. Occurrence of secondary
fungal infections especially
infection by
aspergillosis, is cause of high mortality of infected. Application GM test that detects existence of
antibodies against Aspergillus
antigens and usage of different type of immunosuppressive preparation can increase longevity of graft and patients in solid
organ transplantation program.
Aspergillosis is treated with
voriconazole and surgery, and sometimes graft-
nephrectomy if needed. Recommendation is that in all immunocompromised hosts and organ transplant recipient should have been tested with GM test.