Editorial: Tuberculosis in Post-Liver Transplant Recipients—A Road Less Traveled!

In the last decade, despite improvement in survival after liver transplantation (LT), the scourge of infections remains troublesome with significant associated mortality (7–88%).[1] Post-LT patients are immunosuppressed and are predisposed to flares of latent or incident infections.[1] Post-LT patients in India, a high burden country for tuberculosis(TB)[2] and liver disease-related immune dysfunction, are predisposed to acquire tubercular infections.[3] While treatment of evident infection through sputum testing, chest radiogram, or molecular testing in a symptomatic patient is clear, a controversy exists regarding the latent TB infections in India.[4] [5] Although guidelines recommend testing, with interferon-gamma release assays (IGRAs), the adherence to such guidance remains suboptimal (up to 30%) worldwide.[4] [5] There are several reasons for nonadherence—lack of data on the rate of pre-transplant latent infections, presumed low prevalence of reactivation of latent infections post-LT,[2] unclear interpretation of tuberculin test, cost of IGRA assays, potential hepatotoxicity, and risk of resistance due to isoniazid use in pre-LT patients, and lack of data to show a reduced incidence of TB infections with latent TB treatment.[6] Nonetheless, radiological evidence of past TB, definite contact with the smear-positive patient, proof of active/past TB in the donor, and recognition of tubercular granulomas in explant liver histopathology are expert recommendations for the treatment of latent/active TB in post-LT patients.[5]