Liver transplantation during anti-TB treatment

Background:Management of tuberculosis (TB) in patients undergoing organ transplantation represents a critical challenge, as induced immunosuppression correlates with bad outcomes and high mortality. Therefore, candidates to organ transplantation diagnosed with TB are generally excluded from transplant waiting list until they complete anti-TB treatment. However, in case of end-stage liver disease, liver transplantation (LT) is the unique life-saving option. Moreover anti-TB treatment may contribute to rapid impairment of liver function, that makes LT even more essential. Therefore, in selected cases, LT may still be considered. Methods: We report two cases of successful LT performed in patients affected by pulmonary TB. Results: CASE 1: A 14-year-old boy from Philippine was diagnosed with pulmonary TB and started on standard anti-TB regimen. Three weeks after he presented fever, nausea and rash; treatment was immediately stopped. Due to the rapid deterioration of clinical conditions and liver function, a liver biopsy was performed revealing fulminant hepatitis. Few days later, about 5 weeks after anti-TB therapy start, a LT was performed. Anti-TB treatment was reintroduced immediately after LT, opting for moxifloxacin, ethambutol and linezolid to reduce the risk of hepatoxicity. A month later p-aminosalicylic acid was added. Later linezolid was replaced by terizidone, due to linezolid-induced neuropathy. Treatment has been continued for 18 months, with clinical and radiological improvement. CASE 2: A 50-year old Ukrainian woman with an alcohol-related liver cirrhosis was diagnosed with pulmonary TB. To avoid hepatotoxic drugs, she was started on levofloxacin, linezolid, amoxicillin/clavulanate and ethambutol. After 3 weeks, a LT was necessary due to acute liver failure. The same anti-TB treatment was gradually reintroduced immediately after LT. A month later linezolid was replaced by isoniazid, considering the recovery of liver function. One year later she completed the treatment, showing clinical and radiological resolution. Conclusion: Both patients underwent successful LT and achieved positive outcome of TB treatment. Our cases suggest that TB is not an absolute contraindication to organ transplantation and case-by-case decision is necessary, especially if transplantation represents the only life-saving opportunity. However, the correct anti-TB treatment strategy in the post-transplant period is still under debate and should be further explored.