Digestive tract infections in kidney and liver transplantation in a single institution

Endoscopic diagnosis of cytomegalovirus infection of upper gastrointestinal tract in solid organ transplant recipients: Hungarian single-center experience

BACKGROUND

Cytomegalovirus (CMV) is considered to be the major cause of upper gastrointestinal (GI) symptoms in organ transplant recipients. In the diagnosis of GI CMV infection the detection of the virus in the mucosa is essential. The aim of the study was to evaluate the significance of CMV, detected in biopsy specimens from stomach and duodenum of solid organ transplant recipients.

METHODS

Data of 227 elective upper endoscopies on symptomatic organ transplant recipients were evaluated for clinical symptoms, endoscopic changes and conventional histologic alterations of mucosal biopsy samples. Qualitative PCR was performed for detection of the presence of CMV-DNA in each biopsy materials.

RESULTS

CMV-DNA was detected in biopsy samples of 91 patients (40.1%) while only in 20 cases (8.8%) the signs of CMV infections were found by conventional histology (p < 0.00001). No considerable differences could be observed in symptomatic, histologic alterations between CMV-PCR positive and negative groups. There were no endoscopic changes in 25.3% of CMV-PCR positive and 5.1% of negative patients.

CONCLUSIONS

Qualitative PCR is an accurate method for the detection of CMV in the mucosa of the GI tract. Further investigations are needed for determination of the exact pathological role of detected CMV.

Clostridium difficile colitis associated with inflammatory pseudotumor in a liver transplant recipient

The aim of this report is to describe a rare complication of clostridium difficile (CD) disease, the occurrence of an inflammatory pseudotumor that caused intestinal obstruction in a liver transplant recipient. A 9-month-old girl underwent liver transplantation for biliary atresia. She was given tacrolimus as primary immunosuppressive therapy. Three months after liver transplantation, she presented with febrile protracted bloody diarrhea and failure to thrive. A diagnosis of post-transplant lymphoproliferative disease associated with Epstein-Barr virus infection was initially made on histological examination of duodenal biopsies. Tacrolimus was discontinued. Despite treatment with anti-CD20 monoclonal antibodies the child's condition deteriorated and she presented with intestinal occlusion. A mass at the ascending colon was seen on the computed tomography scan mimicking lymphoma and the child underwent surgical laparotomy. Histological examination of the mass showed typical pathological lesions of inflammatory pseudotumor and CD pseudomembranous colitis. Diagnosis of CD disease was confirmed upon the identification of CD toxin A in stools. She was successfully treated by metronidazole and gamma-globulin perfusions. Delayed diagnosis and anti-CD20 monoclonal antibodies therapy (associated with hypogammaglobulinemia) possibly played a major role in the severity of CD pseudomembranous colitis and in the occurrence of an inflammatory pseudotumor.

Clostridium difficile colitis after kidney and kidney-pancreas transplantation

OBJECTIVE

To determine the timing and risk factors involved in the development of Clostridium difficile (CD) colitis in kidney and kidney-pancreas transplant recipients.

BACKGROUND DATA

The incidence of CD colitis after kidney and kidney-pancreas transplantation has not been studied in detail. The question of whether the immunosuppressed transplant recipient is more prone to CD colitis and its complications (i.e., megacolon, perforations) and the risk factors involved have not been determined.

METHODS

We retrospectively reviewed our experience in kidney and kidney-pancreas recipients who received transplants between January 1, 1985 and December 31, 1994. We divided these recipients into three groups: pediatric kidney recipients, adult kidney recipients, and kidney-pancreas recipients. For each group, we assessed the timing of infection, primary disease, colitis treatment, and any concurrent complications or risk factors.

RESULTS

Of 1932 transplants, 159 recipients developed post-transplant CD colitis. 132 charts were available for review. Forty-three pediatric kidney recipients developed CD colitis. Their mean age was 3.2 yr; 74% (n = 37) of them developed their colitis during their initial hospital stay, with the mean timing of infection being 33 d. Forty-one (95%) had undergone intra-abdominal placement of the graft, with renal artery anastomoses to the aorta. Fifty adult kidney recipients developed CD colitis. Thirteen (26%) developed colitis during their initial hospital stay, with the mean timing of infection (for all adult kidney recipients) being 15 months. Thirty-nine kidney-pancreas recipients developed CD colitis. Mean timing of infection was 6 months. The overall incidence of CD colitis was 8%, with 16% in the pediatric kidney group, 15.5% in the kidney-pancreas group, and 3.5% in the adult kidney group. The difference in mean timing of infection was significant between the three groups (p < 0.001 for pediatric versus adult kidney recipients, p = 0.002 for pediatric kidney versus kidney-pancreas recipients, and p = 0.2846 for adult kidney versus kidney-pancreas recipients).

CONCLUSION

The incidence of CD colitis is increased in pediatric kidney and kidney-pancreas recipients. Young recipient age ( < 5 yr), female gender, treatment of rejection with monoclonal antibodies, antibiotic use, and intra-abdominal graft placement have been shown to increase the incidence of this disease. Further studies concerning prevention in the high-risk groups are needed.