Arkell, P

Brincat, S

Cooper, P

Cosgrove, C

MacPhee, I

Pan, D

Riley, P

St George's Online Research Archive

L E T T E R T O T H E E D I T O RShould prospective renal transplant recipients bescreened for Strongyloides stercoralis?Paul Arkell 1, Daniel Pan1, Peter Riley1, Philip Cooper2, Ian MacPhee3,Catherine Cosgrove1,2 and Stephan Brincat41Infection Department, St George’s University Hospitals NHS Foundation Trust, London, UK, 2Institute forInfection and Immunity, St George’s, University of London, Cranmer Terrace, London, UK, 3Institute ofMedical and Biomedical Education, St George’s, University of London, Cranmer Terrace, London, UK and and4Department of Nephrology and Transplantation, St George’s University Hospitals NHS Foundation Trust,London, UKCorrespondence to: Paul Arkell; E-mail: paularkell@doctors.org.ukStrongyloidasis is a neglected tropical disease caused byStrongyloides stercoralis, which affects >100 million people, largelyin Africa, Asia and Latin America [1, 2]. Chronic infection can per-sist for decades, and may be asymptomatic or causegastrointestinal, cardiopulmonary or skin symptoms [3]. In someindividuals with specific types of immune suppression (e.g. exog-enous corticosteroids and organ transplantation), rapid replica-tion and dissemination of larvae result in Strongyloideshyperinfection syndrome (SHS), a condition characterized byacute severe illness and high mortality (Figure 1) [4].In 2019, we looked after an Angolan gentleman withrenal transplantation who developed SHS and sadly died [5].FIGURE 1: Spectrum of human disease caused by S. stercoralis.Received: 14.3.2020; Editorial decision: 16.3.2020VC The Author(s) 2020. Published by Oxford University Press on behalf of ERA-EDTA.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited.For commercial re-use, please contact journals.permissions@oup.com725Clinical Kidney Journal, 2021, vol. 14, no. 2, 725–727doi: 10.1093/ckj/sfaa047Advance Access Publication Date: 15 June 2020Letter to the EditorDownloaded from https://academic.oup.com/ckj/article/14/2/725/5857814 by guest on 26 February 2021We subsequently reviewed 264 renal transplant recipients atour centre and found that 30% could be at risk of strongyloidesbased on their likely ethnic origin, which we determined usingOnolytics, a software that assigns the most probable origin ofeach individual based on first name and surname [6] (Figure 2).Eosinophilia prior to transplantation was significantly morecommon in this group (49% versus 36%; P¼ 0.049), as was en-teric bacteraemia after transplantation (10% versus 4%;P¼ 0.046). These could indicate undiagnosed infection. Despitethis, none had been tested. Overall mortality of transplantrecipients was low (6% after a median follow-up duration of4.5 years) and was not associated with country of origin.In the UK, there are no community-level or transplant clinicdata suggesting the prevalence of strongyloidiasis. However, arecent systematic review of migrants originating from endemiccountries and arriving/living in any non-endemic country founda pooled S. stercoralis seroprevalence of 12.2% [7]. Office forNational Statistics data showed that 7.4% of individuals livingin the UK were born in Africa, Asia or Latin America [8].Therefore, somewhere in the region of 0.9% of individuals re-ceiving renal transplantation in the UK could be seropositive forstrongyloides.The risk of SHS in seropositive individuals who undergo or-gan transplantation is not known. A retrospective study inBrazil identified 46 cases among 15 860 transplant recipients(0.3%), but most of these had received pre-emptive anthelmintictreatment [9]. Despite this, international [10] and US [11] trans-plantation guidelines make pragmatic recommendations for se-rological screening of potential recipients. An alternativeapproach would be routine treatment of at-risk individuals us-ing ivermectin (a drug that is both safe and effective for chronicstrongyloidiasis) [12]. UK guidelines only recommend testing fortropical infections in prospective donors [13].We would urge clinicians to consider strongyloidiasis in re-nal transplant recipients if they have ever lived in the tropics.Serological screening (or treatment based on demographic riskfactors alone) may be beneficial and should be considered forinclusion in transplantation guidelines.ACKNOWLEDGEMENTSThe authors would like to thank Mrs Maria Fernandez,Renal Transplant Nurse Coordinator, Department ofNephrology and Transplantation, St George’s UniversityHospitals NHS Foundation Trust.CONFLICT OF INTEREST STATEMENTNone declared. The results presented in this article have notbeen published previously in whole or part, except in abstractformat.REFERENCES1. Genta RM. Global prevalence of strongyloidiasis: critical re-view with epidemiologic insights into the prevention of dis-seminated disease. Rev Infect Dis 1989; 11: 755–7672. Bisoffi Z, Buonfrate D, Montresor A et al. Strongyloides ster-coralis: a plea for action. PLoS Negl Trop Dis 2013; 7: e22143. Nutman TB. Human infection with Strongyloides stercoralisand other related Strongyloides species. Parasitology 2017;144: 263–2734. Buonfrate D, Requena-Mendez A, Angheben A et al. Severestrongyloidiasis: a systematic review of case reports. BMCInfect Dis 2013; 13: 78FIGURE 2: Global map displaying our transplant recipients’ ethnic origin and demographic risk of strongyloides. Numbers within circles display number of individuals.726 | P. Arkell et al.Downloaded from https://academic.oup.com/ckj/article/14/2/725/5857814 by guest on 26 February 20215. Pan D, Arkell P, Stone NRH et al. Delayed Strongyloides ster-coralis hyperinfection syndrome in a renal transplant pa-tient with Pneumocystis jirovecii pneumonia receivinghigh-dose corticosteroids. Lancet 2019; 393: 15366. Lakha F, Gorman DR, Mateos P.Name analysis to classifypopulations by ethnicity in public health: Validation ofOnomap in Scotland. Public Health 2011; 125: 688–6967. Asundi A, Beliavsky A, Liu XJ et al. Prevalence of strongyloidia-sis and schistosomiasis among migrants: a systematic reviewand meta-analysis. Lancet Glob Health 2019; 7: e236–e2488. Office for National Statistics. Population of the UK by Countryof Birth and Nationality. https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/internationalmigration/datasets/populationoftheunitedkingdombycountryofbirthandnationality (9 March 2020, date lastaccessed)9. Miglioli-Galv~ao L, Pestana JOM, Lopes-Santoro G et al. SevereStrongyloides stercoralis infection in kidney transplantrecipients: a multicentre case-control study. PLoS Negl TropDis 2020; 14: e000799810. Clemente WT, Pierrotti LC, Abdala E et al. Recommendationsfor management of endemic diseases and travel medicine insolid-organ transplant recipients and donors: Latin America.Transplantation 2018; 102: 193–20811. Fischer SA, Lu K; AST Infectious Diseases Community ofPractice. Screening of donor and recipient in solid organtransplantation. Am J Transplant 2013; 13 (Suppl 4): 9–2112. Henriquez-Camacho C, Gotuzzo E, Echevarria J et al.Ivermectin versus albendazole or thiabendazole forStrongyloides stercoralis infection. Cochrane Database SystRev 2016; CD007745. doi: 10.1002/14651858.CD007745.pub313. Advisory Committee on the Safety of Blood Tissues andOrgans. Microbiological Safety Guidelines. 2017. https://www.gov.uk/government/publications/guidance-on-the-microbiological-safety-of-human-organs-tissues-and-cells-used-in-transplantation (9 March 2020, date last accessed)Nephrology dialysis Transplatation | 727Downloaded from https://academic.oup.com/ckj/article/14/2/725/5857814 by guest on 26 February 2021

Should prospective renal transplant recipients be screened for Strongyloides stercoralis?

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Should prospective renal transplant recipients be screened for Strongyloides stercoralis?

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