Severe gastrointestinal complications after 1,515 adult kidney transplantations

Tacrolimus-Associated Terminal Ileitis After Kidney Transplantation, Mimicking Crohn Disease: A Case Report

The onset of gastroduodenal ulcers is a frequent complication after transplantation, whereas cases of intestinal ulcers are sporadic and poorly described in the literature. A patient on immunosuppressive therapy with tacrolimus and mycophenolate mofetil after kidney transplant for immunoglobulin A-related glomerulonephritis developed symptoms compatible with Crohn disease 7 months after the transplant. The patient was hospitalized for abdominal pain, diarrhea, fever, and weight loss. Imaging and a colonoscopy showed signs of idiopathic inflammatory bowel disease (IBD) affecting the terminal ileum. Behcet's disease, post-transplant lymphoma, cytomegalovirus, Epstein-Barr virus, or mycobacteria infection were excluded. Mycophenolate mofetil was suspended, and steroid therapy was increased without clinical improvement. Eleven units of blood were required for severe anemia. A further colonoscopy revealed ulcerations involving the cecal fundus, ileocecal valve, and distal ileum with bowel stenosis and suspected ischemia. The patient, therefore, underwent an emergency laparoscopic ileocolic resection. The histologic examination did not reveal clear signs of IBD, ischemia, or viral infection of the ileum. The findings seemed indicative of iatrogenic damage from immunosuppressive therapy. The postoperative course was regular, and after 12 months, the patient was asymptomatic, on low-dose tacrolimus and prednisone therapy. During immunosuppressive therapy, the onset of isolated ileal ulcers, which can mimic IBD, may be a sporadic complication.

Histologic Features of Tacrolimus-induced Colonic Injury

Tacrolimus is a common immunosuppressant used in solid organ transplant recipients. Although most patients develop diarrheal symptoms, data regarding patterns of injury in patients taking tacrolimus are limited. We performed this study to characterize tacrolimus-related features of colonic injury. We retrospectively identified colonic samples from 20 patients receiving tacrolimus monotherapy. Records were reviewed for symptoms, endoscopic findings, other medications, and infections. None of the patients had gastrointestinal infections or used other drugs known to cause colonic injury; none had received mycophenolate within 6 months of presentation. Cases were evaluated for the nature and distribution of inflammation and crypt abnormalities, including distortion, destruction, and apoptosis. Eighteen (90%) patients were solid organ transplant recipients. Seventeen (85%) had gastrointestinal symptoms, particularly diarrhea (75%). More than 50% had endoscopic colitis and 15% had ulcers and/or erosions. Most (90%) cases showed regenerative epithelial changes; apoptotic crypt cells were present in 55% and numerous in 10% of cases. Neutrophilic cryptitis was present in 60% of cases; 35% showed crypt destruction. Plasma cell-rich lamina propria inflammation and crypt distortion were observed in 40% and 25% of cases, respectively. There was no correlation between therapy duration and features of chronic injury. We conclude that tacrolimus can cause symptomatic colitis. Histologic abnormalities are often mild, featuring regenerative crypts and scattered apoptotic debris. However, 40% of symptomatic patients have chronic colitis, most likely reflecting drug-induced immune dysregulation. Pathologists should be aware of these associations because colitis often resolves with decreasing drug dosage rather than treatment directed toward inflammatory bowel disease.

Gastrointestinal symptoms in HIV-positive kidney transplant candidates and recipients from an HIV-positive donor

Gastrointestinal symptoms (GIS) are common in kidney transplant candidates and recipients and may be worsened by HIV. Objective: To determine the frequency and severity of GIS in HIV-positive kidney transplant recipients from HIV-positive donors, and those waiting to receive one. A GIS rating scale (GSRS) was completed by 76 participants at baseline and at 6 months. GIS frequency was defined as having at least one symptom (GSRS > 1). Severity was indicated by the GSRS score. Transplant candidates: GIS frequency was 88.9% and 86.3% at baseline and 6 months respectively. Indigestion was the most frequent (79.6% and 66.7% at baseline and 6 months), and severe GIS (GSRS 2.3). Women reported global mean (p = 0.030) severity significantly more than men. Transplant recipients: GIS frequency was 95.2% and 76.2% at baseline and 6 months respectively. At both assessment points, indigestion occurred most frequently (85.7% and 61.9% respectively). Highest GSRS was reported for indigestion at baseline (2.33) and at 6 months (1.33). Waist circumference (WC) was positively associated with the severity of constipation GSRS. GIS are common in both groups, especially indigestions. WC in transplant recipients should be monitored.

KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation

The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.

Patient-Reported Gastrointestinal Symptoms and the Association With Quality of Life Following Kidney Transplantation

BACKGROUND

There has been limited study of the prevalence of gastrointestinal symptoms and their impact on the quality of life (QOL) in kidney transplant recipients. The aim of this study was to examine the prevalence and predictors of gastrointestinal symptoms and the association with QOL in kidney transplant recipients.

METHODS

All chronic kidney transplant recipients at the Princess Alexandra Hospital were provided with 3 questionnaires, the Gastrointestinal Quality of Life Index (GIQLI), the Gastrointestinal Symptoms Rating Scale (GSRS), and Structured Assessment of Gastrointestinal Symptoms (SAGIS) scale, to ascertain QOL impairment and to screen gastrointestinal symptom severity. Linear regression was used to determine the predictors of gastrointestinal QOL and gastrointestinal symptom severity.

RESULTS

Of the 343 participants, the median age was 47 (interquartile range [IQR] 36-55) years, 58% were men, 79% were white, 39% had chronic glomerulonephritis, 83% had received their first graft, and median time since transplant was 6.3 (IQR 1.8-13.1) years. Using GSRS, 88% of participants reported at least 1 gastrointestinal symptom, most commonly indigestion (57%) and diarrhea (54%). Using GIQLI, 42% and 38% of participants reported mild and moderate QOL impairment, respectively. Gastrointestinal symptoms were predicted by female sex (coefficient -0.11, 95% CI -0.21 to -0.02) and mycophenolate (coefficient 0.0001, 95% CI 0.0001 to 0.0002), and were associated with poorer QOL (coefficient -0.38, 95% CI -0.45 to -0.30). Similar findings were observed using SAGIS for gastrointestinal symptoms.

CONCLUSIONS

Gastrointestinal symptoms are frequent in kidney transplant recipients, particularly in women and those receiving mycophenolate, and are strongly associated with poorer QOL.

Thoracoscopic Esophagectomy for a Patient With Perforated Esophageal Epiphrenic Diverticulum After Kidney Transplantation: A Case Report

A 58-year-old man who underwent cadaveric kidney transplantation twice presented to hospital with a perforated epiphrenic diverticulum. Computed tomography revealed epiphrenic diverticulitis and right pleural effusion. Upper gastrointestinal fibroscopy showed an epiphrenic diverticulum full of food residue. He was transferred to our hospital, where we performed percutaneous endoscopic gastrostomy under general anesthesia in the supine position before thoracoscopy. Thoracoscopic esophagectomy was performed in the semi-prone position under 6-10 mmHg artificial pneumothorax via the right thoracic cavity. We performed subtotal esophagectomy to remove sources of infection because the esophageal wall surrounding the diverticulum was too thick to close or to perform diverticulectomy. A cervical esophagostomy was constructed after the thoracic procedure. The patient was managed with continuous hemodiafiltration and administered immunosuppressants and steroids to preserve the transplanted kidney. Continuous hemodiafiltration was stopped on postoperative day (POD) 4. The patient was discharged from the intensive care unit on POD 10 and transferred to the original hospital on POD 24 for rehabilitation. The second operative stage was performed on POD 157 at our hospital. We performed gastric tube reconstruction via the ante-sternal route and anastomosed the tube to the cervical esophagus. The postoperative course was uneventful; the patient was transferred to the original hospital on POD 15 after the second operation. Minimally invasive surgery was sufficient to treat perforated epiphrenic diverticulum while preserving the transplanted kidney. We recommend completely removing the source of infection and reducing surgical invasiveness to preserve the transplanted kidney in cases of esophageal perforation following kidney transplantation.

Outcomes Following Colorectal Resection in Kidney Transplant Recipients

BACKGROUND

Kidney transplant recipients (KTR) are at increased risk of requiring colorectal resection compared to the general population. Given the need for lifelong immunosuppression and the physiologic impact of years of renal replacement, we hypothesized that colorectal resection may be riskier for this unique population.

METHODS

We investigated the differences in mortality, morbidity, length of stay (LOS), and cost between 2410 KTR and 1,433,437 non-KTR undergoing colorectal resection at both transplant and non-transplant centers using the National Inpatient Sample between 2000 and 2013, adjusting for patient and hospital level factors.

RESULTS

In hospital, mortality was higher for KTR in comparison to non-KTR (11.1 vs 4.3%, p < 0.001; adjusted odds ratio [aOR] _2.683.59_4.81) as were overall complications (38.5 vs 31.5%, p = 0.001; aOR _1.081.30_1.56). LOS was significantly longer (10 vs 7 days, p < 0.001; ratio _1.421.53_1.65) and cost was significantly greater ($23,056 vs $14,139, p < 0.001; ratio _1.421.54_1.63) for KTR compared to non-KTR. While LOS was longer for KTR undergoing resection at transplant centers compared to non-transplant centers (aOR 1.68 vs 1.53, p = 0.03), there were no statistically significant differences in mortality, overall morbidity, or cost by center type.

CONCLUSIONS

KTR have higher mortality, higher incidence of overall complications, longer LOS, and higher cost than non-KTR following colorectal resection, regardless of center type. Physicians should consider these elevated risks when planning for surgery in the KTR population and counsel patients accordingly.

Routine prophylaxis with proton pump inhibitors and post-transplant complications in kidney transplant recipients undergoing early corticosteroid withdrawal

Surgical stress, corticosteroids, and mycophenolate may contribute to gastrointestinal ulcers/bleeding after kidney transplantation. Prophylactic acid suppression with H2RAs or PPIs is often utilized after transplantation, although unclear if truly indicated after early corticosteroid withdrawal (CSWD). PPIs have been associated with increased risks of Clostridium difficile infection (CDI), pneumonia, and acute rejection. This retrospective cohort study investigated benefits and risks of prolonged PPI use following kidney transplantation and included 286 kidney recipients undergoing CSWD within five d of transplant who were maintained on tacrolimus and mycophenolate mofetil/sodium. Patients on PPI before transplant, H2RA before/after transplant, and/or those with pre-transplant GI complications were excluded. A total of 171 patients received PPI>30 d, mean duration 287 ± 120 d (PPI group); 115 patients were not maintained on acid suppression (No-PPI group). GI ulceration and bleeding events were rare in PPI group (1.2% and 2.3%, respectively) and not observed in No-PPI group (p = NS). The incidence of infectious or hematological complications was not significantly different between groups. The PPI group experienced more biopsy-proven acute rejection (9.4% vs. 2.6%, p = 0.03). No direct benefit was observed with PPI in reducing the incidence of GI ulcers and bleeding events in kidney transplant recipients undergoing early CSWD. Further studies are needed to investigate the association of PPI and acute rejection.

[Infectious complications in autosomal dominant polycystic kidney disease]

Despite advances in the management of autosomal dominant polycystic kidney disease over the past two decades, infection of liver and kidney cysts remains a serious and potentially threatening complication. Kidney cyst infection is the most frequent complication. It is differentiated from hemorrhage by the clinical presentation (mainly the severity and duration of fever), C-reactive protein (CRP) and white blood cells levels, and the density of the suspected cyst on computed tomography. Liver cyst infection occurs more frequently in patients with large cysts volumes. It can be life threatening and has a tendency to recur. In both infections, the best radiological imaging technique is positron emission tomography after intravenous injection of [18F]-fluorodeoxyglucose combined with computed tomography. Treatment with a fluoroquinolone should be continued for 6 weeks. Cyst aspiration is necessary only when cysts are very large and/or when infection is resistant to antibiotic treatment. In patients who are candidates to kidney transplantation, a history of recurrent kidney cyst infection justifies pre-transplant nephrectomy, while a past history of recurrent liver cyst infection or angiocholitis leads to consider liver transplantation. Among extrarenal and extrahepatic complications of polycystic disease, colic diverticulosis is reported to be associated with increased risk of infection in patients on hemodialysis and after kidney transplantation. However, this observation needs to be confirmed.

A prospective analysis of the effects of enteric-coated mycophenolate sodium and mycophenolate mofetil co-medicated with a proton pump inhibitor in kidney transplant recipients at a single institute in China

BACKGROUND

Enteric-coated mycophenolate sodium (EC-MPS) and mycophenolate mofetil (MMF), two prodrugs of mycophenolic acid (MPA), have been used in immunosuppressive regimens. After being taken orally, both of them transform to MPA to achieve immune suppression effects; however, the main site of absorption and metabolism of EC-MPS is different from that of MMF in vivo. Therefore, combined application with related drugs may result in different MPA levels and have different clinical effects in kidney transplant recipients.

OBJECTIVE

To evaluate the efficacy of EC-MPS compared with MMF in Chinese renal transplant patients comedicated with a proton pump inhibitor (PPI).

METHODS

Our subjects were 88 patients who received renal transplants at the 309th Hospital of the Chinese PLA from May 2010 to April 2013. These were made up of two groups including 27 patients with EC-MPS and 61 with MMF. The immunosuppression regimen was EC-MPS/MMF + cyclosporine/tacrolimus + steroid hormone, comedicated with a PPI (omeprazole). The patients' levels of exposure of MPA within 1 week after operation were monitored. Clinical indicators such as incidence of delayed graft function and acute rejection, the rate of change of serum creatinine hemoglobin, leucocytes, and neutrophils, as well as clinical adverse drug reactions and drug conversion were analyzed retrospectively.

RESULTS AND CONCLUSION

The kidney function of patients recovered to normal in both the EC-MPS and MMF groups. The mean concentration to peak (Cmax), the mean half-life (t1/2), and the area under the concentration-time curve (AUC0-12) of MPA in the EC-MPS group were higher than those in the MMF group (P < .05). This indicated that the pharmacokinetic parameters for MPA when EC-MPS is co-administered with a PPI in kidney transplant patients in China is better than for comedication with MMF and a PPI. The MMF group had a higher incidence of drug withdrawal because of higher infection rates, leucocyte decrease, and more gastrointestinal side effects than the EC-MPS group (P < .05). No significant differences in the clinical effect on kidney transplant recipients were observed in the limited observation time.

Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks

BACKGROUND

Anastomotic leak (AL) represents a dreaded complication following colorectal surgery, with a prevalence of 1-19 per cent. There remains a lack of consensus regarding factors that may predispose to AL and the relative risks associated with them. The objective was to perform a systematic review of the literature, focusing on the role of preoperative, intraoperative and postoperative factors in the development of colorectal ALs.

METHODS

A systematic review was performed to identify adjustable and non-adjustable preoperative, intraoperative and postoperative factors in the pathogenesis of AL. Additionally, a severity grading system was proposed to guide treatment.

RESULTS

Of 1707 papers screened, 451 fulfilled the criteria for inclusion in the review. Significant preoperative risk factors were: male sex, American Society of Anesthesiologists fitness grade above II, renal disease, co-morbidity and history of radiotherapy. Tumour-related factors were: distal site, size larger than 3 cm, advanced stage, emergency surgery and metastatic disease. Adjustable risk factors were: smoking, obesity, poor nutrition, alcohol excess, immunosuppressants and bevacizumab. Intraoperative risk factors were: blood loss/transfusion and duration of surgery more than 4 h. Stomas lessen the consequences but not the prevalence of AL. In the postoperative period, CT is the most commonly used imaging tool, with or without rectal contrast, and a C-reactive protein level exceeding 150 mg/l on day 3-5 is the most sensitive biochemical marker. A five-level classification system for AL severity and appropriate management is presented.

CONCLUSION

Specific risk factors and their potential correction or indications for stoma were identified. An AL severity score is proposed to aid clinical decision-making.

Surgical complications following 1670 consecutive adult renal transplantations: A single center study

BACKGROUND AND AIMS

The aim of the study was to clarify the frequency and the sequel of surgical complications occurring within 1 year after renal transplantation.

PATIENTS AND METHODS

Surgical complications after 1670 consecutive adult kidney transplantations performed between 2000 and 2009 were retrospectively analyzed. In 2%, a living-related allograft was used, and 10% were retransplantations. An intravesical technique without stenting was used for the ureteric implantation.

RESULTS

There were 282 surgical complications occurring in 259 (15.5%) transplantations. Ureteral obstruction occurred in 53 (3.1%), lymphoceles in 39 (1.5%), postoperative hemorrhage in 36 (2.1%), and renal vein thrombosis in 22 (1.3%) patients, respectively. Out of the 17 lung emboli, 4 were fatal. Male recipients had twice as much ureteral stenosis as female (2.4 vs 1.2%, p < 0.05), and the opposite was true of urinary leakage (1.8% vs 4.0%, p < 0.025). Five-year patient and graft survival was impaired in patients with complications compared with patients without complications. Five-year patient survival was 92% versus 88% and graft survival 87% versus 74%.

CONCLUSION

Surgical complications impair patient and graft survival after kidney transplantation.

Gastrointestinal complications in renal transplant recipients detected by endoscopic biopsies in a developing country

BACKGROUND

Renal transplantation is the treatment of choice for patients with end-stage renal disease. The renal transplant recipients are susceptible to a variety of gastrointestinal (GI) complications such as infections, ulcer disease, and malignancies.

OBJECTIVES

We aimed to determine the frequency of pathological lesions in GI endoscopic biopsies in recipients of live related renal transplantation in our setting.

METHODS

This retrospective survey was carried out at Histopathology Department of Sindh Institute of Urology and Transplantation, Karachi, from December 2010 to January 2011. All consecutive renal transplant patients of all ages and both genders on regular follow up, presenting with GI complaints and in whom GI endoscopic biopsies were performed, were included. The demographic, clinical, and laboratory data were retrieved from case files and the pathological diagnoses from the original biopsy reports.

RESULTS

A total of 200 consecutive renal transplant patients were enrolled. The biopsies comprised of 19 (9.5 %) esophageal biopsies, 119 (59.5 %) gastric biopsies, 148 (74 %) duodenal biopsies, and 66 (33 %) colorectal biopsies. The main pathological lesions included cytomegalovirus infection in 22 (11 %) of all patients, Helicobacter pylori in 11 (9.2 %) of gastric biopsies, cryptosporidium in 4 (1.6 %), giardiasis in 30 (15 %), immunoproliferative small intestinal disease in 5 (3.4 %), tropical sprue in 33 (15 %), tuberculosis in 3 (2 %) of the small intestinal biopsies, and gastric adenocarcinoma in 1 (1.7 %) gastric biopsy.

CONCLUSION

A wide spectrum of pathological lesions including opportunistic infections was seen in GI endoscopic biopsies in renal transplant patients. Endoscopic biopsies play an important role in the diagnosis and management of GI disease in renal transplant patients.

Strangulated Small Bowel Obstruction After Renal Transplant With No History of Laparotomy: Case Report

Strangulated small bowel obstruction is a complication after abdominal surgery, which is rare in renal transplant patients. A 61-year-old man with a strangulated small bowel obstruction underwent renal transplant surgery 7 years before the current admission. He was admitted to our hospital for abdominal pain, nausea, and abdominal distention. An abdominal computed tomography and an ultrasound examination showed intestinal expansion and fluid collection without ascites. His disease was diagnosed as a small bowel obstruction and conservative treatment was begun. However, because of increasing abdominal pain and the collection of ascites, he underwent an emergency laparotomy and was diagnosed as having a strangulated small bowel obstruction. A fibrous cord had formed between the peritoneum (beside the transplanted kidney) and the root of the sigmoid mesocolon, strangulating the looped ileum and causing bleeding necrosis and hemorrhagic ascites collection. The cord and the necrotic ileum were resected, followed by an end-to-end anastomosis. He was discharged 17 days after the surgery in good condition. This is the first reported case of a person having a strangulated small bowel obstruction by a fibrous cord, who did not have a history of laparotomy after renal transplant. A strangulated small bowel obstruction after a renal transplant in a patient with no history of a laparotomy is a rare, but possible postoperative complications should be considered when making a differential diagnosis.

Renal transplantation in autosomal dominant polycystic kidney disease

In patients with autosomal dominant polycystic kidney disease (ADPKD) evaluated for kidney transplantation, issues related to native nephrectomy, cystic liver involvement, screening for intracranial aneurysms and living-related kidney donation deserve special consideration. Prophylactic native nephrectomy is restricted to patients with a history of cyst infection or recurrent haemorrhage or to those in whom space must be made to implant the graft. Patients with liver involvement require pretransplant imaging. Selection of patients for pretransplant screening of intracranial aneurysms should follow the general recommendations for patients with ADPKD. In living related-donor candidates aged <30 years and at-risk of ADPKD, molecular genetic testing should be carried out when ultrasonography and MRI findings are normal or equivocal. After kidney transplantation, patient and graft survival rates are excellent and the volume of native kidneys decreases. However, liver cysts continue to grow and treatment with a somatostatin analogue should be considered in patients with massive cyst involvement. Cerebrovascular events have a marginal effect on post-transplant morbidity and mortality. An increased risk of new-onset diabetes mellitus and nonmelanoma skin cancers has been reported, but several studies have challenged these findings. Finally, no data currently support the preferential use of mammalian target of rapamycin inhibitors as immunosuppressive agents in transplant recipients with ADPKD.

A clinically significant interaction between tacrolimus and multiple proton pump inhibitors in a kidney transplant recipient

The shared metabolism of PPIs and tacrolimus through the CYP enzyme system has been associated with clinically significant drug interactions, especially in patients who are classified as CYP 2C19 PMs. However, existing data are conflicting, indicating that a single mechanism does not account for all interactions. A drug interaction between tacrolimus and omeprazole, esomeprazole, but not lansoprazole, occurred in an 18-yr-old female kidney transplant recipient classified as a CYP 2C19 extensive (normal) metabolizer. This case suggests that further research is needed to establish the definitive mechanism of this potentially serious drug-drug interaction. Physicians prescribing PPIs in organ transplant recipients with tacrolimus immunosuppression should consider close pharmacokinetic monitoring of tacrolimus when starting or switching a PPI.

Colorectal complications of end-stage renal failure and renal transplantation: a review

AIM

End-stage renal failure (ESRF) and renal transplant recipients are thought to be associated with an increased risk of colorectal complications.

METHOD

A review of the literature was performed to assess the prevalence and outcome in both benign and malignant colorectal disease.

RESULTS

No prospective randomized studies assessing colorectal complications in ESRF or renal transplant were identified. Case series and case reports have described the incidence and management of benign colorectal complications. Complications included diverticulitis,infective colitis, colonic bleeding and colonic perforation. There was insufficient evidence to associated iverticular disease with adult polycystic kidney disease.Three population-based studies have shown up to a twofold increased incidence of colonic cancer but not rectal cancer for renal transplant recipients. Bowel cancer screening (as per the general population) by faecal occult blood testing appears justified for renal transplant patients; however, evidence suggests that consideration of starting screening at a younger age may be worthwhile because of an increased risk of developing colonic cancer.Two population-based studies have shown a threefold and 10-fold increased incidence of anal cancer for renal transplant recipients. A single case–control study demonstrated significant increased prevalence of anal human papilloma virus (HPV) and intraepithelial neoplasia (AIN)in patients with established renal transplants.

CONCLUSIONS

Despite the lack of high-level evidence,ESRF and renal transplantation were associated with colorectal complications that could result in major morbidity and mortality. Bowel cancer screening in this patient group appears justified. The effectiveness of screening for HPV, AIN and anal cancer in renal transplant recipients remains unclear.

Helicobacter pylori before and after the kidney transplantation

Renal disease is often accompanied by significant gastrointestinal symptoms, and Helicobacter pylori is related to these disorders. There is a paucity of data about the endoscopic findings of kidney recipients. HLA-class II genes have been repeatedly investigated for predisposition to H. pylori infection. The aim was to evaluate the H. pylori infection rate, study the relationship between HLA antigens and H. pylori, and assess the post-transplant gastrointestinal disorders. Data of 709 uraemic patients were collected for seroepidemiologic study; 58.7% of patients were male and the mean age was 45.1 years. The endoscopic results of 543 kidney transplant recipients were analysed; their mean age was 49.5 years and 56.9% were male. Of 709 patients, 49.37% were seropositive for H. pylori. Prevalence of H. pylori decreased strongly with the year of birth. Significant difference was observed in the occurrence of HLA-DR12 according to H. pylori serology. Twenty-nine per cent of endoscopies showed ulcer disease in the first 3 months, more frequent (p = 0.0014) than later. The presence of H. pylori was verified in 20.9% of cases, less than in the general, and in the uraemic population (p < 0.0001). There was no association between the presence of H. pylori and ulcer (p = 0.28). Steroid pulse treatment for rejection was not associated with more ulcers (p = 0.11).

Diverticulitis in transplant patients and patients on chronic corticosteroid therapy: a systematic review

BACKGROUND

The clinical course of diverticular disease in immunosuppressed patients is widely believed to be more severe than in the general population. In this study we systematically reviewed the literature regarding the epidemiology and clinical course of diverticulitis in immunosuppressed patients. Our goal was to develop recommendations regarding the care of this group of patients.

METHODS

Using PubMed and Web of Knowledge we systematically reviewed all studies published between 1970 and 2009 that analyzed the epidemiology, clinical manifestation, or outcomes of treatment of diverticulitis in immunosuppressed patients. Keywords of "transplantation," "corticosteroid," "HIV," "AIDS," and "chemotherapy" were used.

RESULTS

Twenty-five studies met our inclusion criteria. All of these studies focused on the impact of diverticulitis in patients with transplants or on chronic corticosteroid therapy. The reported incidence of acute diverticulitis in these patients was approximately 1% (variable follow-up periods). Among patients with known diverticular disease the incidence was 8%. Mortality from acute diverticulitis in these patients was 23% when treated surgically and 56% when treated medically. Overall mortality was 25%.

CONCLUSIONS

Our study summarizes evidence that patients with transplants or patients on chronic corticosteroid therapy 1) have a rate of acute diverticulitis that is higher than the baseline population and 2) a mortality rate with acute diverticulitis that is high. Further research is needed to define whether these risks constitute a mandate for screening and prophylactic sigmoid colectomy.

High frequency of ulcers, not associated with Helicobacter pylori, in the stomach in the first year after kidney transplantation

BACKGROUND

Although gastrointestinal (GI) symptoms are very frequent in organ transplant patients, there is a paucity of data about the endoscopic findings of kidney recipients.

METHODS

Two thousand one hundred and thirty-five kidney transplants were performed between 1994 and 2007. During that period, 672 gastroscopies were performed in 543 of those patients. Their mean age was 49.5 years and 56.9% were male. Immunosuppressive combinations included cyclosporine-mycophenolate-steroids, cyclosporine-steroids and tacrolimus-mycophenolate mofetil-steroids. Ninety-eight percent of the patients received acid suppression therapy.

RESULTS

The rate of clinically significant endoscopic findings was 84%. Macroscopic findings included inflammation in 46.7%, oesophagitis in 24.7%, ulcer in 16.9% and erosions in 14.8% of cases. Twenty-nine percent of endoscopies showed ulcer disease more frequently in the first 3 months (P=0.0014) after transplantation than later, and 45.7% of all ulcers developed in the first year. The presence of Helicobacter pylori was verified in 20.9% of cases, less than in the general, and also in the uraemic population (P<0.0001). There was no association between the presence of H. pylori and ulcers (P=0.28). Steroid pulse treatment for rejection was not associated with more ulcers (P=0.11); the use of mycophenolate mofetil increased the risk of erosions by 1.8-fold.

CONCLUSION

More than 25% of all kidney recipients required upper endoscopy in their 'post-transplant life'; the prevalence of 'positive findings' and ulcer disease was higher than in the general population (P<0.0001). The most vulnerable period is the first 3 months. Mycophenolate mofetil had an impact on GI complications, whilst the presence of H. pylori in the transplant population is not associated with the presence of ulcers.

Two cases of severe de novo colitis in kidney transplant recipients after conversion to prolonged-release tacrolimus

Diarrhea is a frequent complication in patients after solid organ transplantation. We describe two cases of severe new onset colitis in kidney transplant recipients that developed shortly after the introduction of the therapy with prolonged-release formulation of tacrolimus replacing standard twice daily formulation of tacrolimus in one case and cyclosporine A in the second case. Both patients developed severe, intermittent bloody diarrhea with abdominal pain, weight loss, dehydration and worsening graft function that required immediate hospitalization. The symptoms did not diminish after dose reduction or withdrawal of mycophenolic acid derivatives. After excluding bacterial, viral, fungal, and parasite infections, colonoscopy with colonic biopsy was performed in both patients, which revealed features typical of colitis. Both patients received mesalazine until the symptoms stopped. In one of the patients, standard formulation of tacrolimus was immediately reintroduced. The second patient was given everolimus in an acute phase of diarrhea. Although the two cases presented in this report cannot fully support a causal relationship between the prolonged-release tacrolimus and colitis, they should increase awareness among transplant physicians and prompt more close monitoring of such potential side effects as a part of the pharmacovigilance plan for a new formulation of the well-established immunosuppressive drug.

Gastrointestinal cytomegalovirus infections in organ transplant patients

A cytomegalovirus (CMV) az immunszupprimált szervtranszplantált betegek egyik veszélyes fertőzése. A transzplantáltak 80-90%-ánál a fertőzés inaktív; a tünetekkel járó CMV-betegség gyakorisága 30-40%-os. Gastrointestinalis CMV-betegség a szervátültetettek mintegy 10%-ában fordul elő, a kórkép a tápcsatorna bármelyik szakaszát érintheti. A CMV-betegség leggyakrabban a nyálkahártya károsodásával, fekélyekkel, eróziókkal, vérzésekkel jár, oka lehet a tápcsatorna motilitási zavarának, ritkábban gastrointestinalis gyulladásos teriméknek, perforációknak. A diagnosztika alapja az endoszkópos vizsgálat biopsziás mintavétellel. A biopsziás minta szövettani vizsgálatakor keresni kell a CMV-fertőzésre jellemző cytomegaliás sejteket intranukleáris („bagolyszem”) és intracitoplazmatikus zárványokkal. A vírus kimutatására számos mikrobiológiai, immunhisztokémiai és molekuláris biológiai módszer létezik. Igazolt kórkép esetén a kezelés kettős: az elváltozásoknak, tüneteknek megfelelő gasztroenterológiai kezelés mellett meg kell kezdeni az antivirális terápiát általában intravénás ganciclovirrel és/vagy orális valganciclovirrel. Lényeges a betegség kialakulásának megelőzése is: a magas rizikójú betegcsoportban általános profilaxis javasolt per os valganciclovirrel, speciális esetekben hiperimmunglobulinnal; közepes kockázat esetén a mikrobiológiai surveillance eredménye alapján preemptív kezelés kezdhető.

Seroprevalence of Helicobacter pylori in Central-European uraemic patients and its possible association with presence of HLA-DR12 allele

OBJECTIVES

Renal disease at any stage is often accompanied by significant gastrointestinal symptoms, and Helicobacter pylori (H. pylori) is closely related to these disorders. A debate is still ongoing on the clinical significance of coexisting uraemia and H. pylori. HLA-class II genes have been repeatedly investigated for predisposition to H. pylori infection. The aim of our work was to evaluate the infection rate among uraemic patients, and study the relationship between HLA antigens and H. pylori serologic status in the same cohort.

MATERIALS AND METHODS

Data of 709 uraemic patients were collected and analyzed from 2001-2006. 58.7% of patients were male, 41.3% were female, mean age was 45.1 years (SD: +/-14.65). Microlymphocytotoxicity assay was used for typing of HLA class I, PCR-SSP for typing HLA class II alleles and enzyme immunofluorescency for specific H. pylori IgG.

RESULTS

Of 709 patients, 49.37% were seropositive for H. pylori. Age of H. pylori positive patients was 48.9 versus 41 years of negatives (P<0.0001). Prevalence of H. pylori decreased strongly with year of birth. Significant difference was observed in the occurrence of HLA-DR12 according to H. pylori serology. Of patients carrying DR12, 27 (73%) were H. pylori positive and 10 (27%) were negative [P=0.0037; risk ratios (RR): 2.76].

CONCLUSION

H. pylori infection rate and its decrease with year of birth was the same in the uraemic patients and in the normal population, according to specific prevalence figures. Frequency of HLA-DR12 was the same as in the general population; consequently, it might be a possible risk factor for H. pylori seropositivity, at least in a Central-European population.

Outcome of patients on renal replacement therapy after colorectal surgery

PURPOSE

Patients on renal replacement therapy are reported to have a high complication rate after abdominal surgery, the result of uremia and immunosuppression. A review of this group of patients undergoing colorectal surgery was undertaken.

METHODS

Seventy-three separate colorectal operations were performed for 44 patients. Thirty-eight patients were on dialysis and 35 had a renal transplant. Data (coexisting disease, preoperative blood results, operative details, complications, and colorectal POSSUM score) were completed for each surgical event.

RESULTS

Forty-two elective and 31 emergency procedures were performed. Infective complications were common (overall 60 percent). There were two anastomotic leaks in the elective group, but five leaks from seven emergency anastomoses. Stomas were frequently raised. Ninety percent of patients who survived and had a defunctioning stoma underwent a successful reversal. The overall major complication rate after elective and emergency surgery was 19 and 81 percent, respectively, and mortality was 5 and 26 percent, respectively.

CONCLUSIONS

Renal patients have a high rate of complications after colorectal surgery, and emergency surgery has a significant risk of anastomotic leak. Primary anastomosis should be avoided in all patients undergoing emergency intestinal resections. Subsequent surgery to restore intestinal continuity is possible in 90 percent of patients with far fewer complications.

Clinicians underestimate gastrointestinal symptoms and overestimate quality of life in renal transplant recipients: a multinational survey of nephrologists

Gastrointestinal (GI) symptoms are common in renal transplant recipients and are associated with impaired health-related quality of life (HRQoL). We investigated clinician attitudes to GI symptoms and HRQoL in these patients by surveying 145 nephrologists from Sweden, Denmark, Finland, and Norway. In total, 79 clinicians responded. They estimated that 20% of their patients experienced GI discomfort and that 36% had impaired HRQoL. We previously conducted a survey of the renal transplant recipients treated by these clinicians, in which 92% reported troublesome GI symptoms and 53% had impaired HRQoL compared with the general population. Nephrologists were more likely to manage GI symptoms by reducing immunosuppressant dose (87%) than by switching medication to one with fewer GI side effects (66%). We conclude that clinicians appear to underestimate the prevalence of GI symptoms and impaired HRQoL. Improving patient-clinician communication could lead to more informed management, resulting in better HRQoL and increased graft survival.

Gastrointestinal complications in renal transplant recipients: MITOS study

INTRODUCTION AND METHODS

An epidemiologic multicenter study was performed to evaluate the prevalence and management of gastrointestinal (GI) complications in solid organ transplant patients. A total of 1788 recipients were included, 1132 of which corresponded to renal transplanted patients.

RESULTS

The mean age for the renal transplanted patients was 52 +/- 13.2 years. The mean time from the transplantation was 5.4 +/- 5.4 years. 17.7% showed some pretransplant GI disease, while 53% presented this type of complication in the posttransplant period. Diarrhea was the most prevalent GI complication (51.5%) and digestive perforation was the GI disorder that affected the patients daily living the most. From the patients with GI complications, 71% received pharmacological treatment, using gastric protectors in 91.3% of the cases. Regarding immunosuppressive drugs, in 30.9% of the cases the dose of the drug was reduced, in 9.3% discontinued temporarily and in 7.5% discontinued permanently. These changes mainly affected the MMF (89%, 83% and 74% for dose change, temporary and permanent discontinuation, respectively).

CONCLUSIONS

The prevalence of GI complications in renal transplant exceeded 50%, and affected patients' daily living. The management of these complications was based on treatment with gastric protectors, dose reduction and/or partial or definitive MMF discontinuation.

Increased Prevalence of Gastrointestinal Symptoms Associated with Impaired Quality of Life in Renal Transplant Recipients

BACKGROUND

Immunosuppressive therapies have been associated with gastrointestinal (GI) side effects, which may impair health-related quality of life (HRQoL).

METHODS

In this survey, 4,232 renal transplant recipients from Denmark, Finland, Norway, and Sweden completed the Short-Form 36 (SF-36) questionnaire and the Gastrointestinal Symptom Rating Scale (GSRS). SF-36 scores were compared with country norm values. Multiple logistic regression analysis was used to identify immunosuppressants associated with GI symptoms.

RESULTS

The prevalence of troublesome GI symptoms (GSRS>1) was 83% for indigestion, 69% for abdominal pain, 58% for constipation, 53% for diarrhea, 47% for reflux, and 92% for any GI symptom. Compared with the general population, HRQoL was most commonly meaningfully impaired in the general health dimension (53% of patients). The presence and severity of GI symptoms were associated with worse HRQoL. Tacrolimus showed a significant association with diarrhea (odds ratio [OR]: 1.7; 95% confidence interval [CI]: 1.4-2.0) and constipation (OR: 1.3; 95% CI: 1.1-1.6), and sirolimus with indigestion (OR: 2.9; 95% CI: 1.0-8.1) and abdominal pain (OR: 2.2; 95% CI: 1.1-4.4).

CONCLUSIONS

GI symptoms are associated with impaired HRQoL in the renal transplant population. Managing GI symptoms by careful choice of immunosuppressants should be a focus for improving HRQoL in renal transplant recipients.

Gastrointestinal complications following transplantation

Gastrointestinal complications are common after kidney, liver, pancreas, heart, and lung transplantation. Complications can include gastrointestinal conditions preceding the transplantation, viral, fungal, and bacterial gastrointestinal infections, and gastrointestinal side effects of medications including immunosuppressive agents. Establishing the etiology of gastrointestinal complaints is often difficult because any one or a combination of these factors might be contributory in the same patient.

Cytomegalovirus infection with multiple colonic perforations in a renal transplant recipient

Cytomegalovirus (CMV) continues to be potentially the most important pathogen affecting organ transplant recipients. Severe gastrointestinal complications have been reported to occur in about 10% of renal transplant recipients, sometimes with dramatic presentations. We report the case of a 57-year-old CMV-seropositive woman with end-stage renal failure who developed CMV-related colonic multiple perforation 30 days after cadaveric CMV-positive renal transplantation. CMV pp65 antigenemia test and CMV-PCR had always been negative on all the weekly controls routinely performed in the postoperative period. Only after the sudden onset of this complication did the antigenemia and PCR become positive. The relationship between infection and perforation has been established beyond any doubt, as the histology of the resected colonic segment revealed florid CMV infection with evidence of typical inclusions in both macrophages and endothelial cells. Colonic perforations are often fatal in transplant recipients because of inability to contain the perforation, and only a rapid diagnosis and an aggressive surgical treatment can improve the prognosis.