IS IT WORTH TREATING LATENT TUBERCULOSIS IN POTENTIAL LIVING DONOR RENAL TRANSPLANT RECIPIENTS WITH IGRA POSITIVITY IN MYANMAR?

Myanmar is one of the high tuberculosis burden countries. Patients with end stage renal disease have low immunity. And, they are going to receive immunosuppressive drugs to prevent rejection after living donor renal transplant. Active pulmonary tuberculosis is one of the contraindications for transplant; it is obvious in sputum examination for Mycobacterium tuberculosis and chest radiograph. In those without features of active tuberculosis, blood test for IGRA is done. IGRA positivity in them indicates latent tuberculosis. Whether to treat or not to treat with anti-tubercular therapy in potential living donor renal transplant recipients with IGRA positivity is a controversial issue.

A hospital based interventional study was conducted in one selected public hospital in Myanmar from January 2020 to December 2024. Blood for IGRA test was done to potential living donor renal transplant recipients prior to transplant after exclusion of active-tuberculosis by chest radiograph and sputum examination for acid fast bacilli.  Isoniazid and rifampicin were given daily for 3 months under supervision if IGRA test was positive. Side effects were monitored. They underwent living donor renal transplant after completion of anti-tubercular therapy. Either anti-thymocyte globulin or basiliximab was used as induction therapy. They received corticosteroids, tacrolimus and mycophenolate mofetil as immunosuppressive therapy. They were reviewed monthly clinically (appetite, weight, fever, cough and respiratory system examination). And chest radiograph was done at Month 1, Month 6 and one year, then six monthly and at any time if they had respiratory symptoms for more than 2 weeks. Follow up period was 3 years.

A total of 76 potential recipients were enrolled initially. Three cases had active pulmonary tuberculosis so that they were excluded. Blood tests for IGRA was done in 73 cases and positivity was found in 43.8% (32 out of 73). Combined isoniazid and rifampicin therapy was given to 32 cases with IGRA positivity after obtaining informed consent. Regarding their radiological findings, chest radiograph was normal in 81.3% (26/32). Pleural thickening was noted in 15.6% (5/32) and hilar calcification was seen in one patient (3.1%). Possible predisposing  factor for latent tuberculosis was recorded in half of the cases; diabetes mellitus 25% (8/32), SLE 9.4% (3/32) and past history of pulmonary tuberculosis 15.6% (5/32). All cases tolerated anti-tubercular therapy. None of them developed liver toxicity. They did  have  neither clinical symptoms nor new radiological features suggestive of pulmonary tuberculosis till 3 years after transplant. 

Table (1) Possible predisposing  factor for latent tuberculosis in potential living donor renal transplant recipients with IGRA positivity  (n=32)

Prescribing isoniazid and rifampicin therapy for 3 months to potential living donor renal transplant recipients with latent tuberculosis (IGRA positivity) in Myanmar was safe and effective to prevent pulmonary tuberculosis till 3 years after transplant.