Updated diagnosis and graft involvement for visceral leishmaniasis in kidney transplant recipients: a case report and literature review

Abstract

Purpose: Visceral leishmaniasis (VL) has become a rising concern to transplantation teams, being associated with graft dysfunction and reduced survival of renal transplant recipients. Here, we describe a case of VL occurring in a kidney transplant (KT) recipient in Italy, a country in which Leishmania infantum is endemic and we reviewed the literature on the clinical course and diagnosis of VL in KT recipients residing or travelling to southern Europe.

Results: The VL case was diagnosed 18 months after transplant and 28 days after the onset of symptoms by quantitative PCR (qPCR) on peripheral blood. A graft biopsy showed renal involvement, and PCR performed on graft tissue displayed the presence of Leishmania DNA. The retrospective confirmation of Leishmania-positive serology in a serum sample collected before transplantation, as well as the absence of anti-Leishmania IgG in the graft donor strongly suggest that reactivation of a latent parasitic infection caused VL in the current case.

Conclusion: VL is often underdiagnosed in transplant recipients, despite the presence of latent Leishmania infection being reported in endemic countries. This case report, as well as the literature review on leishmaniasis in KT recipients, underline the importance of rapid VL diagnosis to promptly undergo treatment. Serology is scarcely sensitive in immunocompromised patients, thus molecular tests in peripheral blood should be implemented and standardized for both VL identification and follow-up.

Keywords: Infection; Kidney; Leishmania; Transplantation.

Fig. 1

Molecular diagnosis and monitoring and histological evaluation of visceral leishmaniasis in a kidney transplant recipient. a–c Time course of parasitological and laboratory parameters in the index patient. Parasitaemia was measured by quantitative real-time PCR (qPCR) before and after anti-leishmanial treatment (L-Amb). Detection of kDNA by qPCR was set up as described in Mary et al. [8]. The standard curve was created from Leishmania DNA extracted from 5 × 10⁶ promastigotes of the L. infantum reference strain MHOM/TN/80/IPT1, performing serial dilution to 0.0005 parasites. Detection of kDNA reached the sensitivity of 0.05 parasite equivalents/ml. d. Histology examination of the kidney biopsy shows interstitial fibrosis and tubular atrophy (Trichrome stain, 10×). sCreat; serum creatinine levels. WBC; white blood cells. PLT platelets. Eq.par. equivalent parasites