TB Prophylaxis in Patient 1 Week After Kidney Transplantation?
What are the recommendations for latent tuberculosis (TB) prophylaxis in a 58-year-old patient 1 week after kidney transplantation with a positive PPD (28 mm) who developed hepatitis (aminotransferase levels > 5x normal) requiring hospitalization after 2 months of INH?

Gerardo Negron, MD

This is a difficult question with no good answer. Any advice on this case would also depend on details that are not available, such as: Was there an attempt in the past to treat this patient with INH? If so, how long ago was it? Did the patient recover from hepatitis? Was the diagnosis of hepatitis based on elevated enzymes? Was a liver biopsy done? And is the patient in a high-risk category for development of TB?

If the clinical setting had been of INH hepatitis at the time of INH administration, it would be risky to restart INH. The options for treatment of latent TB include hepatotoxic agents (ie, isoniazid, rifampin, or rifampin in combination with pyrazinamide). If the risk of hepatotoxicity is substantial, you may also want to consider the possibility of clinical follow-up including periodic chest x-rays (without prophylaxis) to make sure that the patient does not develop evidence of active TB. The issue of latent TB management is summarized nicely in an article published in MMWR in 2000.