Do we Need to Screen Uremic Patients for Toxoplasmosis before Kidney Transplantation?

AUTHORS

Seyed Seifollah Beladi Mousavi 1 , Mohammad Faramarzi 2 , *

1 Department of Nephrology, Imam Hospital, Jundishapour University of medical sciences, Ahwaz, IR Iran

2 Student Research Committee, Ahvaz JundiShapour University of Medical Sciences, Ahvaz, IR Iran

How to Cite: Seifollah Beladi Mousavi S, Faramarzi M. Do we Need to Screen Uremic Patients for Toxoplasmosis before Kidney Transplantation?, Shiraz E-Med J. 2013 ; 14(4):e18283. doi: 10.17795/semj18283.

ARTICLE INFORMATION

Shiraz E-Medical Journal: 14 (4); e18283
Published Online: October 1, 2013
Article Type: Research Article
Received: May 8, 2013
Revised: July 10, 2013
Accepted: September 20, 2013
Crossmark

Crossmark

CHEKING

READ FULL TEXT
Abstract

Background: Toxoplasmosis can cause serious complications among persons with weakened immune systems and therefore in solid organ transplant patients.

Objectives: The aim of the study was to evaluate the value of screening for toxoplasma antibody titers in the donors and recipients candidate for renal transplantation in Ahvaz city, Iran.

Materials and Methods: In a cross sectional study from March 2010 to April 2012, we evaluated donors and recipients who referred to our kidney transplant center in Naft Hospital, Ahwaz, Iran.Routine pre transplante laboratory testes including liver function and toxoplasma IgG and IgM antibody were performed.

Results: A total of 52 people, 30 donors (20 male and 10 Female) and 22 recipients (12 male and 10 female) were included in the study. Mean age of donors and recipients were 30.32 ± 6.75 years and 45.09 ± 10.57 years respectively. The marker of HBV and HCV infection were negative in 100% of recipients and donors. Toxoplasma IgG antibody was positive in 45.45 percent of recipients (N = 10) and 63.33 percent of donors (N = 19) but there was no statistically significant difference between them (P = 0 .057) and between males and females (P = 0.74). Toxoplasma IgM antibody was negative in 100 percent of recipients (N = 22) and 93.33 percent of donors (N = 28).

Conclusions: According to seropositivity for toxoplasma infection in about half of donors and recipients candidate for kidney transplantation, we should perform screening for this infection to avoid kidney donation from seropositive donor to seronegative recipient.

Keywords

Kidney Transplantation Toxoplasmosis Toxoplasma Antibody

Copyright © 2013, Shiraz University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Toxoplasmosis is a parasitic infection caused by an intracellular protozoan parasite called Toxoplasma gondii. The parasite infects a very large variety of species especially warm-blooded animals including humans, but the primary host is the felid (cat) family. This Infection in humans is mainly acquired by ingestion of food or water which is contaminated with oocytes shed by cats or by eating undercooked or raw meat containing tissue cysts. Transmission from mother to fetus is another significant source of human infections in some countries (1, 2). Toxoplasmosis is a worldwide infectious disease; its spread in different parts of the world depends on various factors such as location, life, age and level of host immunity and genotype of parasite strains (3).

Although infection with toxoplasma gondii in humans is very common, however most cases of toxoplasma gondii infections in patients with normal immune system are asymptomatic and therefore do not require treatment. Occasionally, mild symptoms such as influenza-like symptoms, headache, body aches, and lymphadenopathy which is the most significant manifestation may develop among patient with normal immune system (1).

In patients with impaired immune system, toxoplasmosis most often occurs among those with defects of T-cell–mediated immunity, such as patients with acquired immunodeficiency syndrome AIDS or those with hematologic malignancies and solid organ transplants especially heart transplant patients.

A small but significant percentage of these patients eventually develop severe clinical manifestations of toxoplasmosis including encephalitis, retinochoroiditis, sepsis syndrome/shock, myocarditis, polymyositis, or hepatitis which are very rare in immunocompetent patients (4-10).

Although toxoplasmosis may be infrequent among renal transplant recipients, the morbidity and mortality of this complication is high and it can be presented as a life threatening disease (5, 6, 8-10).

2. Objectives

The aim of the study was to evaluate the value of screening for toxoplasma antibody titers in the donors and recipients candidate for renal transplantation in Ahvaz city, Iran.

3. Materials and Methods

In a cross sectional study, we studied 52 candidate for renal allograft recipients and living donors who referred to our kidney transplant center before transplantation from March 2010 to April 2012.

A standardized questionnaire was used to collect socio demographic data (for donors and recipients), cause of ESRD, date of onset of renal replacement therapy (RRT), kind of RRT and length of time receiving RRT.

Blood samples were taken from recipients and donors for check of IgG and IgM anti Toxoplasma antibodies. The levels of antibodies were determined using sensitive enzyme-linked immunosorbent assay (ELISA) method (5).

All patients and donors were also screened for, HBsAg, and hepatitis C antibody (anti-HCV) by using ELISA method. All samples were also tested for liver function tests including alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels by a colorimetric method. Colorimetry is a technique used to determine the concentration of colored compounds in solution (7). The medical laboratories were performed to the patients free of cost by the hospital.

All data were collected in accordance with Ahvaz Jundishapour University of Medical Sciences Ethical Committee Acts.

3.1. Statistical Analysis

At the end of the work, statistical analyses were carried out by use of statistical package for social sciences (SPSS) version 15 software. For statistical analysis, prevalence rates and 95% confidence intervals (CI 95%) were calculated. Chi-square tests were performed to evaluate the distribution of variables and characteristics associated with Toxoplasmosis infection. Statistical significance was assessed at the 0.05 probability level in all analyses.

4. Results

In overall, 52 people who referred to our kidney transplant center were enrolled for this study. 30 people were donors, 20 male (66.66%) and 10 female (33.33%), and 22 people were recipients, 12 male (54.54%) and 10 female (45.45%). As it shown in table (1), Mean age of donors and recipients were 30.32 ± 6.75 years and 45.09 ± 10.57 years respectively. Minimum age in recipients was 19 and maximum was 66 years a. In donors minimum age was 20 and maximum was 60 years.

Toxoplasma IgG antibody was positive in 45.45% of recipients (N = 10) and 63.33% of donors (N = 19). Toxoplasma IgM antibody was negative in 100% of recipients (N = 22) and 93.33% of donors (N = 28). (Table 1 and Figure 1)

Table 1. General Information and Laboratory Data in Recipients and Donors
DonorRecipient
Female10 (45.45%)12 (54.54%)
Male20 (66.66%)10 (33.33%)
Mean age30.32 ± 6.7545.09 ± 10.57
IgG anti toxoplasma (+)63.33%45.45%
IgG anti toxoplasma (-)37.63%54.55%
IgM anti toxoplasma (+) 6.66%0%
IgM anti toxoplasma (-)93.33%100%
LFTNormalNormal
HBVall negativeall negative
HCVNo positiveNo positive
Toxoplasma Antibody in the Recipients and the Donors
Figure 1. Toxoplasma Antibody in the Recipients and the Donors

Although the prevalence of Toxoplasmosis infection was higher in donors, there was no statistically significant difference between them (P = 0 .057) and between males and females (P = 0.74).

Liver Function tests (SGOT and SGPT) were at normal range in both recipients and donors. It was in donors 25 ± 5 and 23 ± 7 and in recipients 28 ± 8 and 26 ± 5 respectively. Markers of HBV infection were negative in all recipients and donors and HCV antibody was negative in 100% of recipients and donors too.

Causes of ESRD of recipients were high blood pressure in eight patients (36.36%), diabetes mellitus in six patients (27.27%), unknown in five patients (22.72%), glomerulonephritis in two patients (9.09%), polycystic kidney disease (PKD) in 1 patient(4.54%) (Table 2).

Table 2. The Causes of ESRD in the Recipients
Cause of ESRDPatients, No. (%)
Hypertension8 (36.36)
Diabetes mellitus6 (27.27)
Unknown5 (22.72)
Glomerulopathy2 (9.09)
PKD1 (4.54)

5. Disscusion

Toxoplasmosis is a well-known opportunistic pathogen among AIDS and immunocompromised patients including solid organ transplant recipients. It can be presented as a life threatening disease with high morbidity and mortality among these patients. Immunosuppressive treatments could reactivate latent tissue cysts and turning solid organ transplant recipients into active toxoplasmosis (11-15).

Toxoplasmosis has also been recognized as a potential donor-to-host transmission infection after solid organ transplantation mainly from seropositive heart transplant donors to seronegative recipients, as the myocardium is one of the sites were cysts of toxoplasma gondii are located (16-18).

Toxoplasmosis transmitted from the seropositive donor to seronegative recipients has also been described after liver and renal transplantation. However compare to heart transplant patients, it is much more infrequent (16). It has been reported in 57% of heart recipients, 20% of liver recipients and less than 1% in kidney recipients (13).

The results of our study show that, the prevalence of toxoplasma IgG antibody and exposure to the infection in adult general population candidate for kidney transplantation in Khuzestan province, Iran, is high and about half of donors (63.33%) and recipients (45.45%) have Toxoplasma IgG antibody before transplantation.

The result of our study is similar to the result of Gharavi et al. In a prospective cohort study, they evaluate the IgM and IgG anti-toxoplasma antibody among 102 kidney transplantation recipients in Tehran province, Iran, before and 3 months after transplantation by using ELFA and ELISA techniques. The results of this study show that 63.7% of recipients have Toxoplasma IgG antibody before transplantation. No one of them have Toxoplasma IgM antibody (13).

In the other study, Vejdani examined IgM and IgG anti–toxoplasma antibodies in 50 donors and recipients before kidney transplantation in Kermanshah province, Iran and showed that IgG and IgM anti–toxoplasma antibodies are positive among 36% and 2% of the donors and 52% and 2% of the recipients (19).

According to the prevalence of toxoplasma antibody in our study and also Vejdani and Gharavi et al studies, and according to the potential reactivation of the disease and transmission of infection from seropositive donors to seronegative recipients after renal transplantation, we suggest that both the recipient and the donor candidate for kidney transplantation should be routinely tested for IgM and IgG anti–toxoplasma antibodies before transplantation to avoid kidney donation from seropositive donor to seronegative recipient and to better follow-up of seropositive recipients for reactivation of latent tissue cysts following immunosuppressive treatments (12-19).

This approach is very important especially in countries like us which about half of all the healthy people (donors) and recipients have IgG anti–toxoplasma antibodies in the plasma and therefore if we don’t perform above screening method, some of toxoplasma -negative recipients may be toxoplasma infected from toxoplasma - positive donor (12-19).

In our study, we didn’t found any association between seropositivity for toxoplasma antibodies, renal failure and exposure to dialysis. In addition, the prevalence of toxoplasmosis infection was higher in donors compare to recipients in our study. Although it was not statistically significant difference, however the results of our study are different with the results of Aufy et al study (20).

Aufy et al classified 78 patients with renal disease who had Toxoplasma gondii antibodies according to the renal status and showed that Toxoplasma IgG and IgM antibodies are positive among 36.8% and 10.5% of renal failure patients not on haemodialysis and 56.7% and 16.7% of patients on regular haemodialysis respectively. In the final of the study, the author suggested that that the more the exposure to dialysis is associated with the more the risk of toxoplasmosis in contrast to our study (20).

Toxoplasmosis may be presented as a life threatening disease among patients with impaired immune system such as solid organ transplants recipients. It has also been recognized as a potential donor-to-host transmission infection after solid organ transplantation. Immunosuppressive treatments could also reactivate latent tissue cysts and turning solid organ transplant recipients into active toxoplasmosis.

The results of our study show that about half of donors and recipients candidate for kidney transplantation in Khuzestan province, Iran have toxoplasma IgG antibody and exposure to the infection. Therefore we suggest that both the recipient and the donor candidate for kidney transplantation should be routinely tested for IgM and IgG anti–toxoplasma antibodies before transplantation to avoid kidney donation from seropositive donor to seronegative recipient and to better follow-up of seropositive recipients for reactivation of latent tissue cysts following immunosuppressive treatments.

References

  • 1.

    Montoya JG, Kovacs JA, Remington JS. Principles and practice of infectious diseases. 2000; : 3170 -98

  • 2.

    Velimirovic B. Toxoplasmosis in immunosuppression and AIDS. Infection. 1984; 12(5) : 315 -7 [PubMed]

  • 3.

    Montoya JG, Liesenfeld O. Toxoplasmosis. Lancet. 2004; 363(9425) : 1965 -76 [DOI][PubMed]

  • 4.

    Engstrom RJ, Holland GN, Nussenblatt RB, Jabs DA. Current practices in the management of ocular toxoplasmosis. Am J Ophthalmol. 1991; 111(5) : 601 -10 [PubMed]

  • 5.

    Gharavi MJ, Oormazdi H, Roointan ES. A comparative study on sensitivity and specificity of conventional and unconventional IgG and IgM assay for diagnosis of toxoplasmosis. Iran J Sch Public Health. 2008; 4 : 42 -5

  • 6.

    Hebraud B, Kamar N, Borde JS, Bessieres MH, Galinier M, Rostaing L. Unusual presentation of primary toxoplasmosis infection in a kidney-transplant patient complicated by an acute left-ventricular failure. NDT Plus. 2008; 1(6) : 429–432

  • 7.

    Housecroft CE, Constable EC. Chemistry: an introduction to organic, inorganic, and physical chemistry. 2006;

  • 8.

    Robin P, Carlos VP. Infections in solid-organ transplant recipients. Clin Mic Rev. 1997; 10(107)

  • 9.

    Trikha I, Wig N. Management of toxoplasmosis in AIDS. Indian J Med Sci. 2001; 55(2) : 87 -98 [PubMed]

  • 10.

    Walker M, Zunt JR. Parasitic central nervous system infections in immunocompromised hosts. Clin Infect Dis. 2005; 40(7) : 1005 -15 [DOI][PubMed]

  • 11.

    David TJ, William AP. Medical parasittology. 2006; : 140 -9

  • 12.

    Dietrich U, Maschke M, Dorfler A, Prumbaum M, Forsting M. MRI of intracranial toxoplasmosis after bone marrow transplantation. Neuroradiology. 2000; 42(1) : 14 -8 [PubMed]

  • 13.

    Gharavi MJ, Jalali S, Khademvatan S, Heydari S. Serological evaluation of anti-toxoplasma IgM and IgG antibodies in renal transplant recipient's before and aftertransplant by ELFA, ELISA and ISAGA methods. 13(2) : 177 -82

  • 14.

    Ryning FW, McLeod R, Maddox JC, Hunt S, Remington JS. Probable transmission of Toxoplasma gondii by organ transplantation. Ann Intern Med. 1979; 90(1) : 47 -9 [PubMed]

  • 15.

    Seong DC, Przepiorka D, Bruner JM, Van Tassel P, Lo WK, Champlin RE. Leptomeningeal toxoplasmosis after allogeneic marrow transplantation. Case report and review of the literature. Am J Clin Oncol. 1993; 16(2) : 105 -8 [PubMed]

  • 16.

    Luft BJ, Naot Y, Araujo FG, Stinson EB, Remington JS. Primary and reactivated toxoplasma infection in patients with cardiac transplants. Clinical spectrum and problems in diagnosis in a defined population. Ann Intern Med. 1983; 99(1) : 27 -31 [PubMed]

  • 17.

    Mayes JT, O'Connor BJ, Avery R, Castellani W, Carey W. Transmission of Toxoplasma gondii infection by liver transplantation. Clin Infect Dis. 1995; 21(3) : 511 -5 [PubMed]

  • 18.

    Orr KE, Gould FK, Short G, Dark JH, Hilton CJ, Corris PA, et al. Outcome of Toxoplasma gondii mismatches in heart transplant recipients over a period of 8 years. J Infect. 1994; 29(3) : 249 -53 [PubMed]

  • 19.

    Vejdani M. Evaluation of Toxoplasma antibody levels in 50 kidney donors and recipients. J Kermanshah Univ Med Sci. 2008; 13(1)

  • 20.

    Aufy SM, Mahgoub AM, Saadi MG, Adel Elmallawany M. Serological detection of Toxoplasma gondii in chronic renal failure patients and renal transplant recipients. J Egypt Soc Parasitol. 2009; 39(3) : 943 -50 [PubMed]

  • COMMENTS

    LEAVE A COMMENT HERE: