Gastrointestinal complications in renal transplant recipients

Novel Potassium Binders for Early Postoperative Hyperkalemia in Kidney Transplant Recipients: A Single-Center Experience

PURPOSE

Evaluate the safety/efficacy of novel potassium binders (patiromer, sodium zirconium cyclosilicate [SZ-9]) for early postoperative hyperkalemia following kidney transplantation.

METHODS

Retrospective, single-center, cohort study of deceased-donor kidney recipients transplanted between 1/2018 and 12/2020. Potassium-binder use was evaluated from immediately posttransplant until discharge. Potassium binders were administered ≥2 hours before/after medications.

RESULTS

A total of 179 patients were included, 24 (13%) of whom received potassium binders (16 [67%] patiromer, 7 [29%] SZ-9, 1 [4%] both) for a mean of 2.5 (±3.18) doses. Peak potassium levels were higher in the potassium-binder group (6.05 vs 5.35 mEq/L; P < .001). More patients on potassium binders transitioned to atovaquone than those on no binders (n = 21 [100%] vs n = 112 [75%], respectively; P = .005). Delayed graft function (DGF) was observed in 100 (56%) patients, with a higher proportion receiving potassium binders (18 [75%] vs 82 [53%], respectively; P = .042). There was no difference between groups in number of posttransplant dialysis sessions required in the general study population (P = .2), nor in the DGF group (P = .12). No difference was noted in the incidence of ileus (P = .2), or gastrointestinal symptoms (diarrhea, nausea, vomiting; P = .6). Of the 24 patients who received inpatient binders, 9 (37.5%) were discharged and remained on them for a mean of 46 (±49) days.

CONCLUSION

Patiromer and SZ-9 appear safe in the early posttransplant period, but larger prospective trials are needed. Potassium-binder use does not appear to be associated with fewer dialysis sessions in DGF patients, however, they may be used as additional tools for lowering potassium in these patients.

The Role of Vitamin D Metabolism Genes and Their Genomic Background in Shaping Cyclosporine A Dosage Parameters after Kidney Transplantation

Background: Kidney transplantation is followed by immunosuppressive therapy involving calcineurin inhibitors (CNIs) such as cyclosporin A. However, long-term high CNIs doses can lead to vitamin D deficiency, and genetic variations influencing vitamin D levels can indirectly impact the necessary CNIs dosage. This study investigates the impact of genetic variations of vitamin D binding protein (DBP) rs2282679 and CYP2R1 hydroxylase rs10741657 polymorphisms on the cyclosporin A dosage in kidney transplant recipients. Additional polymorphisims of genes that are predicted to influence the pharmacogenetic profile were included. Methods: Gene polymorphisms in 177 kidney transplant recipients were analyzed using data mining techniques, including the Random Forest algorithm and Classification and Regression Trees (C&RT). The relationship between the concentration/dose (C/D) ratio of cyclosporin A and genetic profiles was assessed to determine the predictive value of DBP rs2282679 and CYP2R1 rs10741657 polymorphisms. Results: Polymorphic variants of the DBP (rs2282679) demonstrated a strong predictive value for the cyclosporin A C/D ratio in post-kidney transplantation patients. By contrast, the CYP2R1 polymorphism (rs10741657) did not show predictive significance. Additionally, the immune response genes rs231775 CTLA4 and rs1800896 IL10 were identified as predictors of cyclosporin A response, though these did not result in statistically significant differences. Conclusions:DBP rs2282679 polymorphisms can significantly predict the cyclosporin A C/D ratio, potentially enhancing the accuracy of CNI dosing. This can help identify patient groups at risk of vitamin D deficiency, ultimately improving the management of kidney transplant recipients. Understanding these genetic influences allows for more personalized and effective treatment strategies, contributing to better long-term outcomes for patients.

Exploring Acute Pancreatitis in Kidney Transplant Recipients: A Multicentre Retrospective Cohort Analysis of Incidence, Causes, and Clinical Outcomes

Background: The aim of this multicentre retrospective study is to determine the incidence, etiology, clinical characteristics, and outcomes of kidney transplant recipients diagnosed and treated for acute pancreatitis. Methods: We analyzed data from kidney transplant recipients who received kidney allografts between October 1973 and December 2023 and were diagnosed and treated for acute pancreatitis. Results: Of 2482 patients who received kidney allografts, 10 (0.4%) (5 male) were diagnosed with acute pancreatitis, with a mean age of 48.6 years. Patients were diagnosed with acute pancreatitis between 3 weeks and 24 years after the transplantation. Possible etiologies included cholecystolithiasis, COVID-19, hypercalcemia, postprocedural, use of cannabis, trimetoprim-sulphometoxasole, statins, sirolimus, tacrolimus and obesity. There was no suspected etiology in two patients. Patients were treated with aggressive hydration, pain alleviation and antibiotics if indicated. Four patients developed complications. Local complications included peripancreatic collections, pseudocyst, and abscesses formation, while systemic complications occurred in the form of Cytomegalovirus (CMV) reactivation and urinary tract infection. All patients survived with preserved kidney allograft function. Conclusions: Acute pancreatitis in kidney transplant recipients is rare. However, it may be linked to significant morbidity and mortality. While symptoms may be nonspecific and brought on by a variety of viral and non-infectious illnesses, as well as adverse effects from immunosuppressive medications, a high degree of awareness is required.

Cytomegalovirus-Associated Colitis as a Cause of Lower Gastrointestinal Bleeding in Kidney Transplant Recipients: A Single-Centered Study

Introduction Cytomegalovirus (CMV) is the most common viral pathogen affecting patients undergoing solid organ transplantation. It is often the most important infection for patients who have undergone kidney transplantation. Clinical presentations of cytomegalovirus infection range from asymptomatic infection to organ-specific involvement. This study aimed to determine the frequency of cytomegalovirus-associated colitis in kidney transplant recipients (KTRs) presenting with lower gastrointestinal bleeding. Methods After the approval of the ethical review committee of the Sindh Institute of Urology and Transplantation (ERC-SIUT), this cross-sectional study was conducted at the Department of Hepatogastroenterology at the Sindh Institute of Urology and Transplantation from January 2021 to December 2021. All the KTRs (six months after the transplantation) of either gender and aged between 18 and 65 years, presenting with lower gastrointestinal (GI) bleeding as per the operational definition, were enrolled in the study. Those patients who were either unfit for the endoscopy or refused to give consent were excluded from the study. Colonic biopsies were reviewed by a consultant histopathologist for the features of CMV infection. Results A total of 95 renal transplant recipients of either gender or age above 18 to 65 years with lower GI bleeding were included in the study. Among them, 84 (88.4%) were males, while 11 (11.6%) were females. The mean age of the patients included in the study was 37±11 years. The most common presenting complaint was fresh bleeding per rectum, which was observed in 73 (76.8%). The most common findings observed on colonoscopy in KTRs with bleeding per rectum were colonic ulcers and erosions noted in 41 (43.1%) and 36 (37.3%) patients, respectively. On histopathology, CMV colitis was noted in 21 (22.1%) patients. On comparison of different baseline variables, the presence of fresh bleeding per rectum and the presence of both ulcers and erosions on colonoscopy were the factors significantly associated with CMV colitis in KTRs. Conclusion CMV colitis is a prevalent condition in KTRs, presenting with lower GI bleeding. Despite the significant occurrence, the levels of CMV viremia were not associated with CMV colitis, suggesting that diagnosis should rely on histopathological confirmation. Prophylaxis during periods of high immunosuppression is crucial to reducing the incidence of CMV infections and improving both graft function and patient survival.

Assessment of omeprazole and famotidine effects on the pharmacokinetics of tacrolimus in patients following kidney transplant-randomized controlled trial

Tacrolimus is metabolized in the liver with the participation of the CYP3A4 and CYP3A5 enzymes. Proton pump inhibitors are used in kidney transplant patients to prevent duodenal and gastric ulcer disease due to glucocorticoids. Omeprazole, unlike famotidine, is a substrate and inhibitor of the enzymes CYP2C19, CYP3A4, CYP3A5. The aim of this study was to compare the impact of omeprazole and famotidine on the pharmacokinetics of tacrolimus. A randomized, non-blinded study involving 22 stabilized adult kidney transplant patients was conducted. Patients received the standard triple immunosuppression regimen and omeprazole 20 mg (n = 10) or famotidine 20 mg (n = 12). The study material consisted of blood samples in which tacrolimus concentrations were determined using the Chemiluminescent Microparticle Immuno Assay method. A single administration of omeprazole increased tacrolimus concentrations at 2 h (day 2) = 11.90 ± 1.59 ng/mL vs. 2 h (day 1 - no omeprazole administration) = 9.40 ± 0.79 ng/mL (p = 0.0443). AUC0-6 amounted to 63.07 ± 19.46 ng × h/mL (day 2) vs. 54.23 ± 10.48 ng × h/mL (day 1), (p = 0.0295). AUC2-6 amounted to 44.32 ± 11.51 ng × h/mL (day 2) vs. 38.68 ± 7.70 ng × h/mL (day 1), (p = 0.0130). Conversely, no significant changes in values of pharmacokinetic parameters were observed for famotidine. Omeprazole significantly increases blood exposure of tacrolimus. The administration of famotidine instead of omeprazole seems safer for patients following kidney transplantation. Clinical Trial Registration: clinicaltrials.gov, identifier NCT05061303.

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.

Oft Forgotten Cause of Diarrhea in a Posttransplant Setting

Chronic diarrhoea following a renal transplant is a common clinical manifestation. A large number of possible aetiologies complicate the diagnosis. Invasive testing is frequently conducted in patients with persistent or intractable diarrhoea. We discuss the case of a kidney transplant recipient who developed persistent diarrhoea with a 10-kg weight loss in a 3-week period. The patient was diagnosed with a Cryptosporidium parvum infection after stool screening for atypical organisms. Cryptosporidium has emerged as one of the most prevalent causes of infectious diarrhoea in post-renal transplant settings, particularly in endemic places such as India. The patient responded well to oral nitazoxanide. Post-renal transplant patients are in an immunocompromised state and are at significantly higher risk for getting infection-associated diarrhoea, so an approach for early stool screening for atypical organisms is advised.

Oral candidiasis in patients with kidney transplantation in Iran: prevalence and antifungal susceptibility pattern

Aim: This study aimed to identify Candida species recovered from the oral cavity of patients with kidney transplantation. Materials & methods: Two swabs were taken from the oral cavities of 40 patients before and after transplantation, cultured on Sabouraud dextrose agar, and yeasts identified. Antifungal drug susceptibility testing was performed with fluconazole and itraconazole. Results: Candida glabrata was the most frequently isolated species in patients, followed by Candida albicans and Rhodotorula. C. glabrata isolates from patients before transplantation were resistant to fluconazole, whereas C. albicans was fluconazole-resistant both before and after transplantation. Conclusion: The importance of non-albicans Candida species in the oral cavity of patients sheds light on performing antifungal tests for achieving the best outcome to prevent therapeutic failure.

Drug-Associated Gastropathy: Diagnostic Criteria

Drugs are widely used to treat different diseases in modern medicine, but they are often associated with adverse events. Those located in the gastrointestinal tract are common and often mild, but they can be serious or life-threatening and determine the continuation of treatment. The stomach is often affected not only by drugs taken orally but also by those administered parenterally. Here, we review the mechanisms of damage, risk factors and specific endoscopic, histopathological and clinical features of those drugs more often involved in gastric damage, namely NSAIDs, aspirin, anticoagulants, glucocorticosteroids, anticancer drugs, oral iron preparations and proton pump inhibitors. NSAID- and aspirin-associated forms of gastric damage are widely studied and have specific features, although they are often hidden by the coexistence of Helicobacter pylori infection. However, the damaging effect of anticoagulants and corticosteroids or oral iron therapy on the gastric mucosa is controversial. At the same time, the increased use of new antineoplastic drugs, such as checkpoint inhibitors, has opened up a new area of gastrointestinal damage that will be seen more frequently in the near future. We conclude that there is a need to expand and understand drug-induced gastrointestinal damage to prevent and recognize drug-associated gastropathy in a timely manner.

Characteristics of stroke after liver and kidney transplantation

Background

The mechanism and characteristics of a post-transplantation stroke may differ between liver (LT) and kidney transplantation (KT), as the associated comorbidities and peri-surgical conditions are different. Herein, we investigated the characteristics and etiologies of stroke occurring after LT and KT.

Methods

Consecutive patients who received LT or KT between January 2005 to December 2020 who were diagnosed with ischemic or hemorrhagic stroke after transplantation were enrolled. Ischemic strokes were further classified according to the etiologies. The characteristics of stroke, including in-hospital stroke, perioperative stroke, stroke etiology, and timing of stroke, were compared between the LT and KT groups.

Results

There were 105 (1.8%) and 58 (1.3%) post-transplantation stroke patients in 5,950 LT and 4,475 KT recipients, respectively. Diabetes, hypertension, and coronary arterial disease were less frequent in the LT than the KT group. In-hospital and perioperative strokes were more common in LT than in the KT group (LT, 57.9%; KT, 39.7%; p = 0.03, and LT, 43.9%; KT, 27.6%; p = 0.04, respectively). Hemorrhagic strokes were also more common in the LT group (LT, 25.2%; KT, 8.6%; p = 0.01). Analysis of ischemic stroke etiology did not reveal significant difference between the two groups; undetermined etiology was the most common, followed by small vessel occlusion and cardioembolism. The 3-month mortality was similar between the two groups (both LT and KT, 10.3%) and was independently associated with in-hospital stroke and elevated C-reactive protein.

Conclusions

In-hospital, perioperative, and hemorrhagic strokes were more common in the LT group than in the KT group. Ischemic stroke subtypes did not differ significantly between the two groups and undetermined etiology was the most common cause of ischemic stroke in both groups. High mortality after stroke was noted in transplantation patients and was associated with in-hospital stroke.

Comparison of risk scoring systems for upper gastrointestinal bleeding in patients after renal transplantation: a retrospective observational study in Hunan, China

Background

Upper gastrointestinal bleeding (UGIB) is a common complication in renal transplant recipients. However, the risk stratification value of bleeding scoring systems in these patients is unclear, and data regarding risk factors are limited.

Methods

Clinical data of renal transplant recipients in The Third Xiangya hospital were collected. The predictive ability of Glasgow Blatchford score (GBS), pre-endoscopy Rockall score (pRS), and AIMS65 score were assessed by the area under the receiver operating characteristic curve (AUROC). Risk factors of UGIB were analyzed using binary logistic regression analysis.

Results

A total of 220 patients were enrolled, of which 55 with UGIB. Endoscopy improved the overall survival rate of patients. Glasgow Blatchford score (AUROC 0.868) performed best at predicting UGIB patients who need intervention or death, with a threshold of 10, sensitivity and specificity were 82.4% and 70%, respectively. In terms of predicting mortality, the GBS score was comparable with AIMS65 score (p = 0.30) and pRS score (p = 0.42). Viral hepatitis, intravenous hormone usage, low platelet count, and low albumin level were significant factors associated with UGIB.

Conclusions

The Glasgow Blatchford score (AUROC 0.868) was best at predicting the need for intervention or death. However, their ability to predict mortality was limited, with AUROC less than 0.8. Our study also identified four independent risk factors for renal transplant recipients with UGIB.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02426-3.

The Burden of Gastrointestinal Complaints in Kidney Transplant Recipients Using Tacrolimus With and Without Mycophenolate Mofetil: A Randomized Controlled Study

Background

Tacrolimus (TAC) combined with mycophenolate mofetil (MMF) is the immunosuppressive regimen in the majority of solid organ transplant recipients. Gastrointestinal complaints are frequent, which is considered predominantly a side effect of MMF. However, systematic research in this field is lacking. The aim of this study is to systematically investigate the burden of gastrointestinal complaints in TAC-treated kidney transplant recipients with and without MMF.

Methods

In a single-center, open-label, randomized controlled trial, low immunological risk recipients were randomized to either TAC and MMF or to TAC monotherapy from 6 months after kidney transplantation onwards [NTR4672],. They filled in the Gastrointestinal Symptom Rating Scale questionnaire, which covers five dimensions (abdominal pain, reflux, indigestion, constipation, and diarrhea), 6, 12, and 15 months after transplantation.

Results

Seventy-nine recipients were randomized and 72 completed all questionnaires (34 TACmono and 38 TAC/MMF). At baseline, the mean age was 59 years with 72% male, mean BMI 28 kg/m2, eGFR 55 ml/min/1.73m2, mean daily dose MMF 1200 mg and TAC 5.8 mg, with trough levels of 2.1 mg/L and 7.4 ug/L. Six months after transplantation, 75% of recipients reported troublesome symptoms (score ≥3). Diarrhea was the most troublesome (mean 3.3) and discontinuing MMF significantly reduced it (mean Δ score between month 6 and 15 TAC/MMF -0.9 vs. TACmono -1.8, p=0.03). In recipients with troublesome symptoms, abdominal pain (2.7 to 1.8, p=0.003), indigestion (2.8 to 2.3, p=0.012), and reflux (2.9 to 1.7, p=0.007) significantly decreased over time, independent of MMF use.

Conclusion

The majority of kidney transplant recipients with TAC and MMF experienced troublesome gastrointestinal symptoms 6 months after transplantation. While constipation remained troublesome, indigestion, abdominal pain, and reflux improved over time by month 15. Diarrhea only improved after discontinuing MMF.

The pharmacogenetics of mycophenolate mofetil in Tunisian renal transplant patients

Aim: The effects of variants in IMPDH, UGT1A9, UGT1A8, UGT2B7 and SLCO1B1 genes on the efficacy and safety of mycophenolate mofetil (MMF) in the Tunisian population were investigated. Materials & methods: A total of 245 kidney transplant patients being treated with MMF were recruited and cotreated with cyclosporine or tacrolimus. Genotyping was performed using the polymerase chain reaction-restriction fragment length polymorphism method. MMF, cyclosporine and tacrolimus trough levels were measured by immunoassay. The AUC (AUC_0-12hMPA) was estimated by a Bayesian method. Results: In the tacrolimus-treated group, anemia and diarrhea were associated with the UGT1A9-98C and UGT1A9-275T alleles, respectively (p < 0.05). In the cyclosporine-treated group, leukopenia was associated with the SLCO1B1-521T allele (p < 0.05). Both groups had an increased risk of rejection (p < 0.05) associated with the variant alleles of IMPDH2-3757T>C, UGT1A9-2152C>T and UGT1A9-275C>A and the common allele of SLCO1B1-388A>G. However, no significant association was found between the studied genotypes and AUC_0-12hMPA or cotreatment levels. Conclusion: The results constitute preliminary evidence for the inclusion of the pharmacogenetics of MMF in kidney pretransplantation evaluations.

Nausea, Vomiting, and Dyspepsia Following Solid Organ Abdominal Transplant

Background and objective

Multiple comorbidities may contribute to high readmission rates post-transplant procedures. In this study, we aimed to assess the rates and factors associated with hospital readmissions for dyspeptic symptoms among transplant patients.

Methods

This was a retrospective analysis of adult patients who underwent solid organ transplants at our institution. Pregnant patients or those patients with preexisting gastroparesis were excluded from the study. Readmissions associated with the International Classification of Diseases (ICD) codes for nausea/vomiting, weight loss, failure to thrive, abdominal pain, and/or bloating were included. Factors associated with 30-day and frequent readmissions (two or more) were explored.

Results

A total of 931 patients with solid organ transplants were included; 54% had undergone kidney transplants while 34% were liver transplants. Of note, 30% were readmitted within the first 30 days after discharge following transplant while 32.3% had frequent readmissions. A post-transplant upper endoscopy (EGD) was performed in 34% with food residue discovered in 19% suggesting gastroparesis. However, since only 22% of these patients had a gastric emptying study, only 6% were formally diagnosed with gastroparesis, which was independently associated with both 30-day [odds ratios (OR): 2.58, 95% confidence intervals (CI): 1.42-4.69] and frequent readmissions (OR: 6.71, 95% CI: 3.45-13.10). The presence of pre-transplant diabetes (35%) was significantly associated with a diagnosis of gastroparesis following transplant (OR: 5.17, 95% CI: 2.79-9.57). The use of belatacept (OR: 0.63, 95% CI: 0.42-0.94, p=0.023) was associated with a decrease in the odds of 30-day readmissions.

Conclusion

A significant number of patients were readmitted due to dyspeptic symptoms after solid organ transplants. Diabetes and gastroparesis were significantly associated with higher odds of readmissions while the use of belatacept appeared to be a protective factor.

Human pluripotent stem-cell-derived islets ameliorate diabetes in non-human primates

Human pluripotent stem-cell-derived islets (hPSC-islets) are a promising cell resource for diabetes treatment^1,2. However, this therapeutic strategy has not been systematically assessed in large animal models physiologically similar to humans, such as non-human primates³. In this study, we generated islets from human chemically induced pluripotent stem cells (hCiPSC-islets) and show that a one-dose intraportal infusion of hCiPSC-islets into diabetic non-human primates effectively restored endogenous insulin secretion and improved glycemic control. Fasting and average pre-prandial blood glucose levels significantly decreased in all recipients, accompanied by meal or glucose-responsive C-peptide release and overall increase in body weight. Notably, in the four long-term follow-up macaques, average hemoglobin A1c dropped by over 2% compared with peak values, whereas the average exogenous insulin requirement reduced by 49% 15 weeks after transplantation. Collectively, our findings show the feasibility of hPSC-islets for diabetic treatment in a preclinical context, marking a substantial step forward in clinical translation of hPSC-islets.

The effect of long-term immunosuppressive therapy on gastrointestinal symptoms after kidney transplantation

OBJECTIVE

We examined the relationship between compliance with long-term immunosuppressive therapy after kidney transplantation and gastrointestinal (GI) symptoms in patients discharged from hospitals in this study.

METHOD

Our study was conducted as a descriptive study with the participation of 114 kidney transplant recipients discharged from the organ transplant center of a training and research hospital. Personal Information Form, Immunosuppressive Therapy Compliance Scale and Gastrointestinal Symptom Rating Scale were used in data collection. The data analysis was performed with IBM Statistical Package for the Social Sciences (SPSS) Statistics 25.

RESULTS

According to the findings, 47.4% of kidney transplant patients were between the ages of 46 and 64, and 80.7% of them were male. 41.2% of kidney recipients used immunosuppressive agents between 91 days and 6 months. Compliance with immunosuppressive therapy was similar in all age groups. It was determined that the recipients between the ages of 18 and 30 experienced GI symptoms the most. In terms of the predictors of GI symptoms, it was determined that mycophenolate mofetil (MMF) was effective in the development of reflux and diarrhoea, cyclosporine in the development of diarrhoea and constipation, and tacrolimus in the development of indigestion, which are (p < 0.05).

CONCLUSION

For kidney recipients to have high compliance with immunosuppressive therapy, it is of great importance that they are able to cope with GI symptoms. Our study showed that GI symptoms increase in direct proportion as the duration of immunosuppressive therapy is prolonged and the level of compliance increases. GI symptoms of kidney transplant patients should be recognized, and recipients should be helped to manage those problems.

The Prevalence of Helicobacter Pylori Infection in Patients with Chronic Kidney Disease Undergoing Hemodialysis

The aim of this study was to analyze the prevalence of Helicobacter pylori infection and gastroduodenal lesions in Montenegrin patients with chronic kidney disease on hemodialysis. The study included 55 hemodialysis patients with dyspeptic symptoms and 50 control subjects with normal kidney function who had also dyspepsia. After dyspepsia assessment by an interview, all subjects underwent gastroduodenoscopy and histopathological analysis of biopsy specimens, taken from the corpus and antrum of the stomach. Helicobacter pylori was confirmed in 50.9% of corpus mucosa i.e. 60.6% of antrum mucosa of maintenance hemodialysis patients. There were no significantly differences in endoscopic findings of the stomach and bacterial presence between the two study groups of participants (p = 0.451), while duodenal lesions were prevalent in control subjects (p < 0.001). The atrophy of corpus mucosa was more common in hemodialysis patients (p = 0.007), especially in those who have been on hemodialysis for a longer time (p < 0.001) and had lower pH (p = 0.011). The prevalence of Helicobacter pylori infection shown an inverse relationship with dialysis duration. Contrary, a positive relationship between Helicobacter pylori and the concentration of bicarbonate was demonstrated (p = 0.031). The prevalence of Helicobacter pylori and atrophic mucosal changes in Montenegrin hemodialysis patients depends on dialysis duration and acid-base balance.

Efficacy and Safety of Switching to Azathioprine for Mycophenolate-Induced Diarrhea in Renal Transplant Recipients

BACKGROUND

Diarrhea is a common adverse effect of mycophenolate treatment in renal transplant recipients. In patients with mycophenolate-induced diarrhea, one option is to switch to mycophenolate to azathioprine. In this study, we aimed to define the safety and efficacy of switching from mycophenolate to azathioprine for mycophenolate-related diarrhea in renal transplant recipients.

METHODS

A total of 177 patients, 59 of whom were switched to azathioprine because of diarrhea and 118 of whom comprised a matched control group without diarrhea and continued mycophenolate treatment participated in this study. We analyzed the effect of switching to azathioprine from mycophenolate on amelioration of diarrhea and graft survival.

RESULTS

We observed that 89.8% of patients who switched to azathioprine because of diarrhea had improved diarrhea complaints. Patients switched to azathioprine because of diarrhea had lower glomerular filtration rates (P < .001) and higher proteinuria (P < .001) compared with the control group before the switch. Patients switched to azathioprine compared with a subgroup of 59 control patients were matched to patients switched to azathioprine in terms of baseline renal function and proteinuria in addition to demographic parameters had higher 10-year graft loss compared with patients who continued mycophenolate (P = .03). Particularly in patients with a glomerular filtration rate <30 mL/min at the time of conversion, the risk of early graft loss was high.

CONCLUSIONS

Although switching from mycophenolate to azathioprine was an effective approach to improve diarrhea, this approach is associated with increased risk of graft loss.

Acute esophageal necrosis following kidney transplantation

We are reporting a case of spontaneous acute esophageal necrosis “black esophagus” of unclear etiology in a kidney transplant recipient. A patient with end-stage renal disease due to IgA nephropathy received a deceased-donor kidney transplant. The surgical procedure was uneventful, without hemodynamic instability. He was started on alemtuzumab for immunosuppression induction followed by maintenance immunosuppression with intravenous methylprednisolone for 3 days, then oral prednisone, mycophenolate mofetil and tacrolimus (a target level between 8 and 10ng/ml) daily. On postoperative day (POD) 3, the patient started to develop significant gastro-intestinal symptoms: epigastric pain, dysphagia, odynophagia, eructation, pyrosis, nausea, and regurgitation of food contents. He was diagnosed with esophageal necrosis by upper endoscopy on postoperative day 4. We describe a successful treatment with supportive therapy and complete recovery despite receiving immunosuppressive therapy. To our knowledge, this case is one of the few reported cases of esophageal necrosis in kidney transplant recipients and the first case that was not associated with clinical risk factors.

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.

The prevalence of pain among patients with chronic kidney disease using systematic review and meta-analysis

Pain is a common but often undertreated symptom in patients with chronic kidney disease (CKD) with a much higher prevalence than in the general population. The aim of this systematic review was to synthesize all available quantitative evidence, in order to gain a better understanding of pain prevalence and pain types in patients with CKD. Four databases and the grey literature were searched until 15th January 2021. Random-effect meta-analyses were conducted with multiple subgroup analyses and meta-regressions to further explore the between-study heterogeneity. The quality of studies included was assessed using the Newcastle-Ottawa scale and the level of evidence was determined using the GRADE approach. One hundred sixteen studies reported data on 40,678 individuals. Results from meta-analyses yielded an overall prevalence of 60% (95% confidence interval 56-64) for pain, 48% (42-55) for chronic pain and 10% (6-15) for neuropathic pain. The prevalence of pain was lower among kidney transplant recipients 46% (37-56) compared with patients undergoing dialysis 63% (57-68) and those with non-dialysis CKD 63% (55-70). Musculoskeletal pain appeared to be the most common pain symptom among patients with CKD managed conservatively 42% (28-56) or receiving dialysis 45% (36-55) whilst abdominal pain was most prevalent in kidney transplant recipients 41% (7-86). Thus, all subgroups of patients with CKD suffer from a high burden of pain. Hence, greater awareness and recognition of this issue is vital to inform policy and service provision in this area.

Herpes simplex virus type 7 and Epstein-Barr virus as strange causes of a gastric ulcer

Esophageal, gastric and duodenal ulcers are found in immunocompromised patients due to virus, mainly cytomegalovirus (CMV), and less frequently Epstein-Barr virus (EBV), varicella zoster virus (VZV) and herpes simplex virus (HSV) type 1 or 2.

Uremic and Post-Transplant Gastropathy in Patients With Chronic Kidney Disease and End-Stage Renal Disease

Gastrointestinal (GI) mucosal lesions are common in chronic kidney disease (CKD), end-stage renal disease (ESRD), and in post-renal transplant period. However, etiology of mucosal lesions pre- and post-transplant is very different. Gastropathy in non-transplant ESRD patients usually develops because of uremia, chronic anemia, and fluctuations in the gastric blood supply during hemodialysis, eventually leading to uremic gastritis. Gastropathy in post-transplant patients tends to be associated with immunosuppressive therapies. Helicobacter pylori infection is more prevalent in uremic patients than in post-transplant patients. Uremia can also lead to uremic arteriolopathy and autonomic nervous system dysfunction, which can present with GI symptoms mimicking uremic gastropathy. Post-transplantation immunosuppressive therapies have been linked to GI mucosal lesions as well. These lesions carry a poor prognostic factor disrupting the function of the GI tract, which in turn affects the pharmacokinetics of the immunosuppressive drugs eventually leading to poor graft survival and increased mortality. Mycophenolate mofetil is one of the agents more associated with intestinal erosions. Recognizing uremic gastropathy and intervening early helps prevent post-transplant GI complications. Acid controlling therapies can be an effective prophylaxis against both gastropathies. Using enteric-coated formulation for immunosuppressive agents may slow down the mucosal insult. Treatment of H. pylori in both patient populations may help prevent further mucosal injury. Lastly, timely screening for symptoms may help start treatment early and prevent progression to serious gastropathy.

Gastroenterological complications in kidney transplant patients

Kidney transplantation is the surgical operation by which one of the two original kidneys is replaced with another healthy one donated by a compatible individual. In most cases, donors are recently deceased. There is the possibility of withdrawing a kidney from a consenting living subject. Usually, living donors are direct family members, but they could be volunteers completely unrelated to the recipient. A much-feared complication in case of kidney transplantation is the appearance of infections. These tend to arise due to immune-suppressor drugs administered as anti-rejection therapy. In this review, we describe the gastrointestinal complications that can occur in subjects undergoing renal transplantation associated with secondary pathogenic microorganisms or due to mechanical injury during surgery or to metabolic or organic toxicity correlated to anti-rejection therapy. Some of these complications may compromise the quality of life or pose a significant risk of mortality; fortunately, many of them can be prevented and treated without the stopping the immunosuppression, thus avoiding the patient being exposed to the risk of rejection episodes.

Endoscopic findings in hemodialysis patients upon workup for kidney transplantation

Upper gastrointestinal (GI) abnormality is believed to be higher in patients with end-stage renal disease (ESRD) which can make a big trouble for whom undergo kidney transplant. We conducted this study to assess upper GI findings of patients with ESRD. In the present retrospective study we recorded upper GI endoscopy results in hemodialysis patients who were candidate for renal transplantation during a 10-year period. We reviewed files of 1256 patients with a mean age of 37.6 ± 13.4 years. Half of patients (50.6%) had an abnormal endoscopy. Two most common abnormalities were mild gastritis (35.6%) and gastro-esophageal reflux disease (16.7%). GI ulcers were observed in 11% of patients. Duodenal ulcer was the most common ulcer which was seen in 6.8% of patients. Helicobacter pylori was positive in 32.9% of patients and correlated with GI lesions (P = 0.000, r = 0.371). Longer dialysis duration and older patients revealed more upper GI abnormality (P = 0 .032, <0.001). As long as more than half of our patients have at least one upper GI involvement, we recommended that endoscopy must be done as a pretransplantation evaluation for patients without symptoms who have risk factors for ulcers.

Giant Gastric Ulcers: An Unusual Culprit

Mycophenolate Mofetil (MMF) is routinely used immunosuppressant in solid organ transplantation is commonly associated with several gastrointestinal (GI) side effects. Here we present a case of giant gastric ulcer of 5 cm from MMF use post cardiac transplant. CASE DESCRIPTION: A 56-year-old male with history of severe ischemic cardiomyopathy post heart transplant was on immunosuppression with MMF, tacrolimus and prednisone for 5 months. He presented with severe epigastric pain and intermittent episodes of melena for 1 month. His pain radiated to back that is worsened with eating. Associated with loss of appetite, vomiting and 16-pound weight loss in 3 months. He never smoked, drank alcohol or used over the counter pain medications. He was profoundly anemic requiring blood transfusions. EGD performed demonstrated very large clean-based ulcer of 5 cm diameter in the body, smaller ulcer of 8 mm diameter in pre-pyloric region and 5-10 small aphthous ulcers in the gastric body and fundus. Gastric biopsies taken from the ulcer were negative for Helicobacter pylori, cytomegalovirus and malignancy. Flexible sigmoidoscopy revealed non-bleeding inflamed internal hemorrhoids. Consequently, MMF was discontinued and switched to azathioprine. He was treated with twice daily proton pump inhibitor therapy with resolution of abdominal pain, improved appetite and weight gain. DISCUSSION: MMF is well known for common GI side-effects such as nausea, diarrhea, vomiting, ulcers, abdominal pain and rarely gastrointestinal bleeding. Few studies reported 3 to 8% incidence of ulcer perforation and GI bleeding within 6 months. Risk of gastroduodenal erosions is nearly 1.83 times for MMF, with the highest lesions associated with MMF-tacrolimus-corticosteroid combination treatment as seen in our patient. Hypothesis is that GI tract is vulnerable because of dependence of enterocytes on de novo synthesis of purines, which is disrupted by MMF. Typically, upper GI mucosal injuries of mucosal irritation leading to esophagitis, gastritis and/or ulcers are seen. Endoscopy is both diagnostic and therapeutic if bleeding gastric ulcers are noted. Minor complications improve with reduction of drug dose or use of enteric coated preparation if feasible. Discontinuation of the drug is main stay in the management of MMF related ulcer disease. Simple medical treatment with either H2-receptor antagonists, proton-pump inhibitors, coating agents, prostaglandins or combination has proven effective in most cases. Considering excellent results with medical management of ulcer, role of surgery is limited.

Chronic mesenteric ischaemia masked by candida esophagitis in a renal transplant patient

Chronic mesenteric ischaemia is a severe disease that is often missed due to its non-specific presentation. Immunosuppressed patients are at risk for infectious gastrointestinal disease, which may further obscure the diagnosis of chronic mesenteric ischaemia. In this case, a patient's symptoms and diagnostic workup were consistent with candida esophagitis. Worsening leukocytosis despite treatment, however, prompted re-evaluation ultimately revealing a superior mesenteric artery thrombus causing mesenteric ischaemia. The patient required urgent surgical intervention for the management of his disease.

Helicobacter pylori, Endoscopic, And Histologic Features Among Kidney Transplant Candidates In Southern Iran

Background

The risks of gastrointestinal disorders and cancer are higher in chronic kidney disease (CKD) patients than the general population. There are only a few published reports on the association of helicobacter pylori (H. pylori) infection, endoscopic findings, and histology in these patients. This study was designed to address these controversial topics among kidney transplant candidates as the first study in southern Iran.

Patients and methods

In this cross-sectional study, patients undergoing renal transplantation in the largest center of southern Iran during 2016–2017 were evaluated for the frequency of H. pylori infection, endoscopic findings, and histology. Gastric endoscopic findings (normal, abnormal non-ulcerative, ulcerative) and histological findings of gastric biopsy (normal/non-significant, inflammation, premalignant lesions (PMLs), malignant lesions) were studied.

Results

In total, 293 patients underwent endoscopy for transplant work up. The mean age (SD) was 47.37 (13.14) years. The most common endoscopic finding was abnormal gastric lesions. Overall, 78.8% patients had abnormal gastric histologic findings, of which 6.1% had PMLs. There was no significant association between laboratory data of patients with H. pylori infection. Of these, 147 (50.2%) patients were positive and the others were H. Pylori negative. Positive H. pylori infection was significantly associated with gastric ulcerative lesions. Positive H. pylori infection was also strongly associated with inflammation (P<0.01), but not significantly associated with PMLs (P=0.99) in gastric histology.

Conclusion

The present study showed that abnormal endoscopic and histologic findings as well as positive H. pylori infection were observed in a large number of kidney transplant candidates, so upper endoscopy with biopsy is an acceptable procedure for these patients. However, further studies are recommended to determine the relationship of H. pylori with abnormal endoscopic and histologic findings considering other confounding factors in kidney transplant candidates as well as the efficacy of H. pylori eradication therapy to improve these abnormal findings.

[Acute abdomen : What the clinician wants to know from the radiologist]

CLINICAL ISSUE

Acute abdominal pain is a prevalent problem in the emergency department. The work-up has to include a broad spectrum of differential diagnoses, which should be narrowed down with respect to frequent diagnoses without overlooking rare but potentially even more severe pathologies.

STANDARD RADIOLOGICAL METHODS

The radiological method of choice for the initial work-up after sonography is computed tomography, which has demonstrated the highest sensitivity and specificity for most findings. Plain film radiographs of the abdomen rarely contribute to the final diagnosis. Magnetic resonance imaging is reserved for selected cases, which are described in this article.

ASSESSMENT

The clinical decision trees and recommendations, which need to be in the report depending on the diagnosis, are of relevance for every radiologist who deals with patients with acute abdominal presentations.

PRACTICAL RECOMMENDATIONS

Knowledge of the clinical diagnostic approach in patients with acute abdomen is an unavoidable prerequisite for optimal cooperation between clinicians and radiologists in acute situations.

Urea and creatinine levels in saliva of patients with and without periodontitis

Despite the fact that saliva contains measurable concentrations of urea and creatinine, it is not widely used in clinical nephrology. One of the reasons is the high inter- and intra-individual variability in the salivary markers of kidney function. We hypothesized that gingival bleeding in patients with periodontitis could contribute to this variability by increasing the concentration of salivary urea or creatinine. Samples were collected from 25 patients with periodontitis and 29 healthy controls. In addition, saliva samples from five healthy volunteers were artificially contaminated with blood. The concentration of urea, but not that of creatinine, was more than twice as high in patients with periodontitis than in controls. Artificial contamination of saliva with blood did not affect the salivary concentration of creatinine. Salivary urea increased only with very high levels of contamination (≥2.5% blood in saliva), but that did not occur in patients. In conclusion, periodontitis increases the concentration of salivary urea, but this is not likely to be a result of contamination with blood. Future studies should investigate the composition of the oral microbiome, specifically regarding how it affects the concentration of salivary urea. Salivary creatinine seems to be a more robust non-invasive marker of renal functions than salivary urea.

Varicella-Zoster Virus-Induced Hepatitis in a Liver Transplant Recipient: A Case Report

Infections after solid organ transplantation are a major cause of mortality and morbidity. Varicella-zoster virus (VZV) infection after solid organ transplantation is rare. Here we present a case presenting with acute hepatitis and shingles after a liver transplantation (LT). A 36-year-old male patient underwent a liver transplantation; 7 months later his liver function tests increased. An examination and test results revealed that he had VZV-induced hepatitis. After VZV treatment, his test results returned to normal levels. Hepatic involvement of VZV infection is rare, but it may be fatal in immunocompromised individuals. Early diagnosis and early initiation of antiviral therapy is important in the control of hepatitis and rare hepatotropic viruses in immunocompromised individuals.

Gastric Mucormycosis in a Renal Transplant Patient Treated with Isavuconazole Monotherapy

Gastrointestinal mucormycosis is a rare infection in solid organ transplant recipients. Our patient, a 79-year-old male, presented with severe dysphagia and odynophagia about 2 weeks after receiving a renal transplant. An upper gastrointestinal (UGI) endoscopy revealed esophagitis and gastric ulceration, the cultures from which grew Rhizopus species. A usual treatment strategy should include Amphotericin B as monotherapy or in combination with Posaconazole or Isavuconazole for such infections. Our patient was treated with Isavuconazole monotherapy, in an effort to minimize renal toxicity from Amphotericin B to the new allograft. Unique to our case was a successful clinical response and resolution of UGI lesions with Isavuconazole monotherapy. Due to the vagueness of presenting symptoms, such infections can be easily missed in an immunocompromised patient which can have tragic outcomes. Prompt diagnosis and modulation of immunosuppression are essential to decrease mortality and morbidity. Isavuconazole is a novel agent and can be used as a monotherapy for such infections, especially in renal transplant recipients.

Etiology of increased cancer incidence after solid organ transplantation

Over the past decades, there has been an encouraging increase in survival after solid organ transplantation. However, with longer life spans, more transplant recipients are at risk of dying with functioning grafts from illnesses such as cancer and cardiovascular conditions. Malignancy has emerged as an important cause of death in transplant recipients and is expected to become the leading cause of death in transplanted patients within the next decade. While it is known that solid organ transplant recipients have a three to five-fold increased risk of developing cancer compared with the general population, the mechanisms that lead to the observed excess risk in transplant recipients are less clear. This review explores the etiology of the increased cancer incidence in solid organ transplant including the effect of immunosuppressants on immunosurveillance and activation of oncogenic viruses, and carcinogenic effects of these medications; the role of chronic stimulation of the immune system on the development of cancer; and the impact of pre-existing cancer risk factors and factors related to end-stage organ disease on the cancer excess incidence in solid organ transplant recipients.

Cecum perforation induced by mycophenolate mofetil after hematopoietic stem cell transplantation: A case report and review of literature

GI perforation after stem cell transplantation is extremely rare and is associated with poor prognosis. In addition, the clinical limitations of MMF are associated with GI intolerance and hematologic suppression. However, the exact mechanism whereby MMF induces changes in GI mucosa is unknown. Currently, there is no definite method to distinguish between GI toxicity associated with MMF and GVHD. It is important to recognize association between MMF and the histologic changes mimicking GVHD, given that GVHD is a significant differential diagnosis in stem cell transplant patients. MMF-induced colitis and GI perforation are extremely rare but should be considered in patients presenting with diarrhea and abdominal pain. Histology and clinical features are helpful to distinguish this condition from ischemic colitis. Early recognition of GI perforation is necessary for proper diagnosis and subsequent intervention. Emergency medical treatment and laparotomy have been shown to reduce the risk of fatal complications in patients presenting with GI symptoms suspected of GI perforation.

Upper gastrointestinal alterations in kidney transplant candidates

Introduction:

The incidence of gastrointestinal disorders among patients with chronic kidney disease (CKD) is high, despite the lack of a good correlation between endoscopic findings and symptoms. Many services thus perform upper gastrointestinal (UGI) endoscopy on kidney transplant candidates.

Objectives:

This study aims to describe the alterations seen on the upper endoscopies of 96 kidney-transplant candidates seen from 2014 to 2015.

Methods:

Ninety-six CKD patients underwent upper endoscopic examination as part of the preparation to receive kidney grafts. The data collected from the patients' medical records were charted on Microsoft Office Excel 2016 and presented descriptively. Mean values, medians, interquartile ranges and 95% confidence intervals of the clinic and epidemiological variables were calculated. Possible associations between endoscopic findings and infection by H. pylori were studied.

Results:

Males accounted for 54.17% of the 96 patients included in the study. Median age and time on dialysis were 50 years and 50 months, respectively. The most frequent upper endoscopy finding was enanthematous pangastritis (57.30%), followed by erosive esophagitis (30.20%). Gastric intestinal metaplasia and peptic ulcer were found in 8.33% and 7.30% of the patients, respectively. H. pylori tests were positive in 49 patients, and H. pylori infection was correlated only with non-erosive esophagitis (P = 0.046).

Conclusion:

Abnormal upper endoscopy findings were detected in all studied patients. This study suggested that upper endoscopy is a valid procedure for kidney transplant candidates. However, prospective studies are needed to shed more light on this matter.

Factors leading to dyspepsia in renal transplant recipients

Introduction

Renal transplantation is the definitive treatment for end stage renal disease. Patients subjected to transplantation require lifelong immunosuppression and are prone to several gastrointestinal disorders. Dyspepsia is a common disorder in these patients. The objective of this study was to determine factors leading to dyspepsia in renal (kidney) transplant recipients.

Methods

It was a cross sectional study conducted at department of hepatogastroenterology and transplant sciences, SIUT Karachi, from 1-6-15 to 1-12-15 for six months. All renal transplanted patients having dyspeptic symptoms for more than 6 weeks. EGD was performed, biopsy specimens obtained from antrum and duodenum, these were sent for histopathological examination. Frequency and percentages were obtained for categorical variables, mean ± SD was calculated for continuous variables. Chi square test was used for categorical variable and student t-test for continuous variables.

Results

Ninety patients were included in the study out of which 64 (71.1%) were males, mean age was 35.82 ± 10.04 years (range: 18-65 years). Gastritis (non H.pylori associated) in 78 (78.6%), duodenitis in 35 (38.9%) and H. pylori infection in 29 (32.2%), renal transplant recipients. Most of the patients belonged to Sindhi ethnicity, 27 (30%), followed by Punjabi. Hypertension was the most common co-morbid condition in our patients found in 29 (32.2%), while most of them don't have any co morbid condition. Duodenitis was found to be associated with tacrolimus use (p = 0.037).

Conclusion

Gastritis is the most common factor accountable for this symptoms, followed by duodenitis and H. Pylori. Patients taking tacrolimus as immunosuppressant are more prone to develop duodenitis.

Decline in prevalence and risk of helicobacter pylori in kidney transplant recipients: A systematic review and meta-analysis

OBJECTIVE

The study's aims were (1) to investigate the prevalence and (2) to assess the risk of Helicobacter pylori (H. pylori) infection in kidney transplant recipients.

METHODS

A comprehensive literature search was performed from inception until September 2016. Studies that reported prevalence, relative risks, odd ratios, or hazard ratios of H. pylori among kidney transplant recipients were included. Pooled risk ratios and 95% CI were calculated using a random-effect model.

RESULTS

Eleven observational studies with 2545 kidney transplant recipients were enrolled. Between year 1990 and 2000, the estimated prevalence of H. pylori among people with kidney transplant was 50% (95% CI: 31% to 68%), with a prevalence of 46% (95% CI: 23% to 70%) in high-income countries and 55% (95% CI: 22% to 86%) in middle-income countries, respectively. From year 2000 to 2016, the estimated prevalence of H. pylori among people with kidney transplant was 35% (95% CI: 26% to 45%), with a prevalence of 28% (95% CI: 19% to 37%) in high-income countries and 45% (95% CI: 38% to 51%) in middle-income countries. Data regarding prevalence of H. pylori infection in low-income countries were limited. The pooled RR of H. pylori in kidney transplant recipients was 0.57 (95% CI: 0.33 to 1.00) when compared to people with non-transplant.

CONCLUSIONS

There has been a decline in prevalence of H. pylori in kidney transplant recipients with the overall estimated prevalence of H. pylori in kidney transplant recipients of 35%, particularly in both high-income and middle-income countries. Also, our meta-analysis demonstrates a potential decreased risk of H. pylori infection in kidney transplant recipients compared with non-transplant populations.

Comparison of Mizoribine and Mycophenolate Mofetil With a Tacrolimus-Based Immunosuppressive Regimen in Living-Donor Kidney Transplantation Recipients: A Retrospective Study in China

BACKGROUND

A retrospective study was conducted to investigate the prevalence of gastrointestinal (GI) symptoms as well as the efficacy and safety of mizoribine (MZR) and mycophenolate mofetil (MMF) in Chinese living-donor kidney transplantation (LDKT).

METHODS

Forty-two recipients enrolled between January 2012 and March 2014 were treated with either MZR (n = 22) or MMF (n = 20). All patients were treated in combination with a tacrolimus-based immunosuppressive regimen, besides the study drugs.

RESULTS

GI symptoms were observed in 1 of 22 patients (4.5%) and 10 of 20 patients (50%) in MZR treatment group and MMF treatment group, respectively (P = .001), during the post-transplantation 1 year. No significant differences in the incidence of acid reflux, bloated stomach feeling, and constipation were observed between the two groups. No recipient developed diarrhea in the MZR treatment group, whereas 30% of the MMF treatment group developed diarrhea (P = .007). The averages of GI symptom severity total score and diarrhea score were significantly lower in the MZR treatment group compare with MMF treatment group. There were no inter-group differences in background characteristics. There were no significant differences in acute rejection rate and clinical findings between these two groups, whereas the prevalence of cytomegalovirus infection and leukopenia were significantly lower in the MZR treatment group. There was no significant difference on adverse events such as hyperuricemia or other adverse events.

CONCLUSIONS

This study demonstrated a significantly lower incidence of GI symptoms for treatment with MZR compared with MMF and good efficacy and safety in Chinese LDKT with MZR.

Incidence, Management, and Risk Factors for Lower Gastrointestinal Bleeding in Renal Transplant Recipients

BACKGROUND

There are limited convincing data regarding management and outcomes of lower gastrointestinal bleeding (LGB) in renal transplant recipients (RTR). The aim of this study was to evaluate incidence, management strategies, and risk factors associated with LGB in RTR.

METHODS

Between January 2004 and December 2013, RTR with LGB were analyzed. LGB was defined as having clinical evidence of hemorrhage after upper gastrointestinal etiology was ruled out.

RESULTS

There were 1578 RTR with a mean age of 50 ± 14 years at the time of transplantation. Mean follow-up time after transplantation was 57 ± 45 months. Forty-five (2.9%) patients had a documented site of LGB. The most common causes of bleeding were colitis and angiodysplasia (n = 17). Mean time to LGB after transplantation was 43 ± 36 months. Twelve patients with LGB required intervention. Three underwent colectomy, endoscopic treatment was utilized in 8, and 1 patient had angiographic embolization to control bleeding. Recurrent LGB developed in 11 patients of 42 patients who did not have surgery at the time of index bleeding. Surgical (n = 1) or endoscopic intervention (n = 4) was required in 5 of recurrent bleeders. LGB was more commonly seen in RTRs who had development of a nonfunctioning kidney (P < .0001). RTR who had an LGB had an increased overall mortality rate (not directly related to the bleeding episode) compared with those who did not have a LGB (P = .001). We did not observe any increased risk of LGB bleeding among patients who were receiving anticoagulant or anti-aggregant treatment agents (P = .76).

CONCLUSIONS

Nonfunctioning kidney after transplant is a risk factor for LGB. Overall mortality rates increased after LGB in RTR. Strategies aiming to prolong transplanted kidney function may reduce the incidence of LGB and improve life expectancy in RTR.

Simultaneous Occurrence of Varicella Zoster Virus-Induced Pancreatitis and Hepatitis in a Renal Transplant Recipient: A Case Report and Review of Literature

INTRODUCTION

Gastrointestinal complications are common after renal transplantation, including oral lesions, esophagitis, gastritis, diarrhea, and colon carcinoma. The differential diagnosis is difficult in this scenario because multiple factors such as drugs, infections, and preexisting gastrointestinal disease come into play.

CASE PRESENTATION

We report a case of varicella zoster virus-induced pancreatitis and hepatitis in a renal transplant recipient. The patient underwent renal transplantation 3 years earlier and now presented with severe pain in the epigastrium radiating to his back and had raised serum lipase levels and skin lesions characteristic of varicella. Liver enzyme levels were also elevated. He was started on a regimen of acyclovir. His pain improved in 24 hours, and liver enzyme levels returned to normal in 48 hours.

DISCUSSION

There is a paucity of literature on the simultaneous occurrence of varicella zoster virus-induced hepatitis and pancreatitis in both immunocompetent and immunocompromised patients. Our case highlights the gastrointestinal complications of varicella infection in immunocompromised patients that may precede the characteristic dermatologic manifestations, and the fact that rarely both hepatitis and pancreatitis may be seen.

A Renal Paratransplant Hernia Causing Complete Small Bowel Obstruction: A Case Report and Review of the Literature

A rare type of acquired internal hernia, the renal paratransplant hernia (RPTH), of which only 11 cases have been reported in the literature so far, can follow renal transplantation. We report a patient who presented with acute abdominal pain and vomiting 6 weeks after renal transplantation in the right iliac fossa. A noncontrast abdominal computed tomography scan showed signs of small bowel obstruction. The patient was taken to the operating room for a midline laparotomy, and RPTH with incarcerated small bowel was diagnosed. The bowel loop was released and found to be viable. The postoperative course was unremarkable. It is unclear whether perioperative peritoneal defects or spontaneous ruptures of lymphoceles into the peritoneal cavity form the basis of this rare type of internal hernia. Surgeons should be aware of this entity and avoid both peritoneal defects and postoperative lymphoceles by paying careful attention to meticulous surgical technique.