Solid Organ Transplantation Among Transplant Candidates With TB Disease

BACKGROUND: Deferral of solid organ transplantation (SOT) in recipients with tuberculosis (TB) disease (active TB) is recommended until anti-tuberculosis treatment (ATT) is completed. However, SOT is often urgent, and there are instances where SOT cannot be safely delayed. METHODS: We report two cases with TB disease who were transplanted before completion of ATT in our institution and searched PubMed, EMBASE, and MEDLINE databases from inception to August 2025, to retrieve all other published cases of Mycobacterium tuberculosis among SOT candidates with active TB disease at time of transplantation. RESULTS: Sixty-four detailed cases were identified while two cohort studies had aggregated data on 101 cases of TB disease among kidney transplant (KT) candidates. The majority of cases were liver transplant (LT) candidates (60/64, 93.7%); the rest were heart (2/64), kidney (1/64), or lung (1/64) candidates. About half of LT candidates were urgently transplanted because of ATT induced hepatic failure (35/60, 58.3%). Among LT candidates, pulmonary tuberculosis was most common (39/60, 65%) followed by extrapulmonary (EPTB) (17/60, 28.3%), and disseminated TB (4/60, 6.7%). ATT was started prior to transplantation in 44/60 (73.3%) candidates, while 16/60 (26.7%) were started after SOT. The majority (40/44, 90.9%) were on first line therapy, with transplantation occurring a median of 54.5 (range 2-180) days after starting ATT. Many ATT regimens were modified in the post-transplant phase (31/44, 70.4%). Of nine mortalities among LT recipients, only one was directly attributable to TB disease. For both cohort studies on KT candidates, EPTB was the most common form of TB disease (44/71 and 26/30). ATT was taken a median of 3.8 and 3 months, respectively, prior to SOT. All continuation phase posttransplant ATT were rifampicin-sparing with median duration of 12.27 and 14 months, respectively. There were no deaths attributable to TB disease. CONCLUSIONS: Favorable outcomes after SOT are feasible despite TB disease and incomplete pre-transplant anti-TB treatment. The urgent need for a life-saving transplant procedure should be weighed against the risks of transplantation in a patient with active tuberculosis. Completion of at least 2-month intensive first-line TB treatment (e.g., isoniazid, rifampicin, pyrazinamide, ethambutol, [HRZE]) is recommended with use of a rifamycin-based regimen to optimize sterilization. Although rifamycins are preferred for treatment, a rifampicin-sparing regimen may be more manageable post-transplantation to avoid drug-drug interactions, especially if longer courses of treatment are used.