A 45-year-old male with a history of a renal transplant 3 years ago, currently on tacrolimus, mycophenolate and prednisolone is admitted to your ICU with pulmonary infiltrates, hypoxia and worsening renal function.
a) What are the potential infectious causes of the respiratory failure? Justify what empirical antimicrobial treatment you would commence. (50% marks)
b) Describe how you would manage his immunosuppressive therapy. (50% marks)
Some candidates answered only part of the question. The relevance of the immunosuppression was not appreciated in some answers and a generic list of infectious causes was given.
The most likely infectious causes are:
Is there any data regarding infectious causes of pulmonary infiltrates in the renal transplant recipient? Sure. Kalra et al (2005) lists multiple organisms, and in fact in most patients several species were simultaneously involved. Tuberculosis, PJP, Candida albicans and swarms of Enterobacteriacea were mentioned. However, these were patients from New Delhi, and so their microbial enemies may differ from those of the Norwegian transplant patients.
Justify your antibiotic choice? Well.
Now, how to manage the immunosuppressants. Three major issues are present:
The KDIGO Clinical practice guideline for the care of kidney transplant recipients and the Australian adaptation thereof are actually somewhat useless for this purpose. Fortunately, there are some good free articles out there (eg. Bafi et al, 2017), as well as paywalled ones (Kalil et al, 2007). In short:
Kalra, Vikram, et al. "Spectrum of pulmonary infections in renal transplant recipients in the tropics: a single center study." International urology and nephrology 37.3 (2005): 551-559.
Bafi, Antônio Tonete, Daniere Yurie Vieira Tomotani, and Flávio Geraldo Rezende de Freitas. "Sepsis in solid-organ transplant patients." Shock 47.1S (2017): 12-16.
Kalil, Andre C., H. Dakroub, and Alison Gail Freifeld. "Sepsis and solid organ transplantation." Current drug targets 8.4 (2007): 533-541.