Immunosuppressants after transplantation protect your new kidney, but also increase your risk of infection. This article explains which pathogens often cause problems after transplantation, how to recognize these problems, and how infections from these pathogens are treated.
As the name already suggests, immunosuppressants reduce (=suppress) the activity of your body's defense system (=immune system). Taking these drugs is especially important after transplantation. This is because your body considers your new kidney as a foreign object. Of course the donor's kidney was tested before your transplant to see if it would be a good match for you. However, a perfect match of all immunological characteristics of donor and recipient is almost impossible. The only time a perfect match would be possible is if the donor and recipient were genetically identical twins.
It is completely normal for your immune system to become suspicious if a foreign organ is placed in your body. In order to try and stop your immune system from rejecting the new kidney, the activity of your immune system has to be slowed down. This is exactly the role that immunosuppressants have.
However, like many other drugs, they have side effects. As you probably know, your immune system recognizes not only foreign bodies, but also viruses, bacteria or fungi (=pathogens) and through its defense mechanisms, helps your body to protect itself from infections with these pathogens. When the activity of your immune system is slowed down, such as is the case after transplantation, these pathogens can present new challenges to your immune system.
What are opportunistic infections?
Your risk for infections after transplant is increased compared to before. But which pathogens are particularly likely to cause infections, and what types of infections play a role in your experience as a person with a transplanted kidney?
It's important to understand that it's not just pathogens in your environment that play a role. Bacteria, viruses and fungi are something quite natural and can be found all over and in your body. Some are harmless, whereas others can lead to illness under certain conditions. This applies, for example, to bacteria or viruses that are currently present in your body but are kept in check by your immune system. Others are in your environment, but only become a challenge for your body when your immune system is suppressed.
Pathogens that are located in your environment are called facultative pathogens. Although this sounds complicated at first, it only means that these germs only lead to illnesses if your immune system is not functioning at full capacity. If these facultative pathogens take advantage of immunosuppression and infect you, this type of infection is called an opportunistic infection. In the section below, we will discuss these pathogens and infections they can cause.
What infections are common after transplantation?
Urinary tract infections (UTIs) are particularly frequent after transplantation. About one-third of all transplant recipients have a UTI at some point. Some UTIs recur despite treatment. This is called a chronic UTI. Symptoms of these infections include burning when urinating and an increased urge to urinate.
Respiratory infections, characterized by cough, shortness of breath, and flu-like symptoms, are also common after transplantation. Diarrhea and fever can also occur and should always be discussed with your transplant team.
Unlike in a healthy state, your immune system cannot fight these infections properly. As such, infections can be more intense and become a real challenge to your health. Therefore, it's important that your transplant team is kept in the loop so that they can provide you with the right treatment.
What viruses and bacteria lead to the infections?
As you already know, the bacteria, viruses and fungi that cause infections after transplantation are different from those that are important to a functioning immune system. Below we have created a brief overview of some of the important pathogens that play a role after transplantation:
1. Cytomegalovirus (=CMV)
Many people become infected with CMV during their adolescence or young adulthood. If you have a functioning immune system, CMV does not cause symptoms and antibodies are formed against the virus to fight it. Up to 60% of all adults have antibodies for CMV.
However, for people who are taking immunosuppressants, exposure to CMV can lead to reactivation of the virus (if antibodies were present) or a primary infection with the virus (if antibodies not present). In both cases, the infected person would experience symptoms. CMV can also be transferred to your body via the donor organ. Therefore, people who have had no previous contact with CMV and have no antibodies against this virus should be especially cautious.
Symptoms of CMV infection include fever, enlarged lymph nodes, and inflammation of the gastrointestinal tract, liver, lungs or nervous system. Diarrhea and conjunctivitis can also occur.
To prevent or detect infection with CMV, testing can be done to see if donors and recipients carry antibodies. If infection is present, the virus can be detected in the blood, intestines, or during respiratory examinations.
To treat a CMV infection, a drug is given that restricts the multiplication of the virus. At the same time, symptoms such as fever, diarrhea, or inflammation can be treated.
2. Pneumocystis jirovecii
Pneumocystis jirovecii is not only a tongue-twister, but also fungus that resides in the lungs of most adults. With a functioning immune system, it poses no real danger. However, in the case of an immune deficiency, it can lead to pneumonia. Therefore, to protect against infection after transplantation, specific antibiotics can be given for a few months following the surgery.
Symptoms of pneumonia caused by this fungus include fever, dry cough, chest pain, fatigue, weight loss, or night sweats.
To detect a Pneumocystis jirovecii infection, imaging (X-ray, CT-scans) of your lungs may be done. Additionally, a sample from your lungs (either coughed up or manually collected from your airways) may be taken for testing.
3. BK virus (BKV)
Nearly all adults - transplanted or not - are infected with BKV. This virus nests in your white blood cells and kidney. It can sometimes cause inflammation of your kidney, ureter and bladder, but only if your immune system is weak. Pretty nasty if we can say so ourselves!
In the beginning of an infection with BKV, there are often no symptoms. Later, you may experience a decrease in kidney function, a backlog of urine, or a bladder infection with bloody urine.
Such an infection occurs in up to 10% of transplant recipients and occurs most often in the first year after transplantation. To detect the virus, your medical team will test your blood and urine samples. Sometimes a small tissue sample of your new kidney is also taken.
4. Influenza and flu viruses
Generally, the flu virus can infect and cause the flu in anyone. Therefore, an annual flu vaccination to protect you from this virus exists. Especially after transplantation, flu and colds can occur more frequently. Therefore, annual flu vaccination is recommended after transplantation.
Unlike vaccinations with live vaccines - in which a small, weakened amount of “live and reproducible” virus is administered - a flu vaccination (= dead vaccine with pathogens that can no longer reproduce) is safe after transplantation. For more on vaccinations before and after transplantation, see the other articles in the Mizu app.
How do I prevent infection after transplantation?
To prevent infection after transplantation, you should make sure your vaccinations are complete and up to date. Some of the common vaccinations should be boostered before or even shortly after transplantation. Others, such as the flu shot, are recommended annually. Only live vaccinations, such as those against mumps, measles, or rubella, should not be given after transplantation because they can lead to infection with the pathogen.
In addition, during and after transplantation, some medications are given, for example, against bacteria (=antibiotics) or viruses (=antivirals) to prevent infections. In order not to weaken your immune system unnecessarily, you should also make sure to take your immunosuppressants strictly according to the prescribed intervals of your medical team. That way, the effect of the medication remains consistent and doesn't fluctuate too much.
As you see, taking your medications (correctly) after transplant is extremely important. With the help of the Mizu app, you can be reminded to take your medication and document it regularly. This way, you can easily keep track of your medications.
How do I recognize an infection after transplantation?
Although each infection has its own symptoms, there are some general signs that can help you recognize an infection. Your infection parameters - especially shortly after transplantation - are monitored in your lab values. These parameters include the so-called C-reactive protein (CRP) and the number of white blood cells. An increase in CRP in particular can indicate an infection.
In addition to your lab values, it's a good idea to take your temperature regularly. If you have a fever (≥ 38 °C), you should contact your transplant team right away. In addition to fever, symptoms such as fatigue, diarrhea, vomiting, coughing or pain when urinating can also be an indication of an infection. In the Mizu app, you can document information, such as your temperature and your lab values, in your logbook. This way you can keep your health under control at all times and are well prepared for quick detection and reaction against typical pathogens.
