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Taneja V, Anand RS, El-Dallal M, Dong J, Desai N, Taneja I, Feuerstein JD. Safety of Biologic and Small Molecule Therapy for Inflammatory Bowel Disease Among Solid Organ Transplant Recipients: Systematic Review and Meta-Analysis. Inflamm Bowel Dis 2024; 30:585-593. [PMID: 37300512 DOI: 10.1093/ibd/izad108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Indexed: 06/12/2023]
Abstract
BACKGROUND Patients undergoing organ transplantation are often on immunosuppressing medications to prevent rejection of the transplant. The data on use of concomitant immunosuppression for inflammatory bowel disease (IBD) and organ transplant management are limited. This study sought to evaluate the safety of biologic and small molecule therapy for the treatment of IBD among solid organ transplant recipients. METHODS Medline, Embase, and Web of Science databases were systematically searched for studies reporting on safety outcomes associated with the use of biologic and small molecule therapy (infliximab, adalimumab, certolizumab, golimumab, vedolizumab, ustekinumab, and tofacitinib) in patients with IBD postsolid organ transplant (eg, liver, kidney, heart, lung, pancreas). The primary outcome was infectious complications. Secondary outcomes included serious infections, colectomy, and discontinuation of biologic therapy. RESULTS Seven hundred ninety-seven articles were identified for screening, yielding 16 articles for the meta-analyses with information on 163 patients. Antitumor necrosis factor α (Anti-TNFs; infliximab and adalimumab) were used in 8 studies, vedolizumab in 6 studies, and a combination of ustekinumab or vedolizumab and anti-TNFs in 2 studies. Two studies reported outcomes after kidney and cardiac transplant respectively, whereas the rest of the studies included patients with liver transplants. The rates of all infections and serious infections were 20.09 per 100 person-years (100-PY; 95% CI, 12.23-32.99 per 100-PY, I2 = 54%) and 17.39 per 100-PY (95% CI, 11.73-25.78 per 100-PY, I2 = 21%), respectively. The rates of colectomy and biologic medication discontinuation were 12.62 per 100-PY (95% CI, 6.34-25.11 per 100-PY, I2 = 34%) and 19.68 per 100-PY (95% CI, 9.97-38.84 per 100-PY, I2 = 74%), respectively. No cases of venous thromboembolism or death attributable to biologic use were reported. CONCLUSION Biologic therapy is overall well tolerated in patients with solid organ transplant. Long-term studies are needed to better define the role of specific agents in this patient population.
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Affiliation(s)
- Vikas Taneja
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rajsavi S Anand
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mohammed El-Dallal
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Cambridge Health Alliance, Harvard Medical School, Boston, MA, USA
| | - Jeffrey Dong
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Nisa Desai
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Isha Taneja
- Massachusetts General Hospital for Children, Harvard Medical School, Boston, MA, USA
| | - Joseph D Feuerstein
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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2
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Wheless WH, Russo MW. Treatment of Primary Sclerosing Cholangitis Including Transplantation. Clin Liver Dis 2024; 28:171-182. [PMID: 37945158 DOI: 10.1016/j.cld.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Primary sclerosing cholangitis is a progressive cholestatic liver disease that causes stricturing of the intra and extrahepatic bile ducts that can lead to cirrhosis and end stage liver disease. Effective medical therapy has been elusive, but a course of ursodeoxycholic acid may be prescribed at doses of 17-23 mg/kg/day for up to a year to determine if a reduction in serum alkaline phosphatase is observed. A number of drugs are under investigation, including FXR agonists with choleretic and antimicrobial properties. Liver transplantation for PSC has one of the highest survival rates, but recurrent PSC is seen in up to 25% of recipients.
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Affiliation(s)
- William H Wheless
- Division of Hepatology, Atrium Health Wake Forest, Charlotte, NC, USA
| | - Mark W Russo
- Division of Hepatology, Atrium Health Wake Forest, Charlotte, NC, USA.
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3
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Ogata M, Kato M, Miyauchi T, Murata-Hasegawa M, Sakurai Y, Shinoda K, Yamazaki H, Shibagaki Y, Yazawa M. De novo Inflammatory Bowel Disease in Kidney Transplant Recipients: A Single-Center Case Series Study. Inflamm Intest Dis 2024; 9:96-102. [PMID: 38628544 PMCID: PMC11021040 DOI: 10.1159/000538334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/08/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction Gastrointestinal complications are common after solid organ transplantation. New-onset inflammatory bowel disease (IBD) after transplantation (de novo) is a major differential diagnosis of diarrhea after liver transplantation (LT) because of its high incidence in the field. However, the incidence of IBD after kidney transplantation (KT) remains unknown. Methods This case series comprised six de novo IBD patients who had undergone KT at our hospital from April 1998 to December 2020. In this period, 232 KT recipients were identified. Participants were analyzed based on their colonoscopy diagnoses. Detailed clinical information regarding both KT- and IBD-related symptoms or outcomes was obtained, and we calculated the incidence of de novo IBD from the date of KT. Results Of the 232 recipients in the median observation period of 6.1 (interquartile range: 2.6, 10.8) years, six recipients (one with Crohn's disease and five with ulcerative colitis) were diagnosed with de novo IBD. The incidence of de novo IBD after KT was 355.8/100,000 person-years (95% confidence interval, 159.8-791.9 per 100,000 person-years). Bloody stools and diarrhea did not always occur, with bloody stools occurring in three and diarrhea in 2 patients at the time of diagnosis. No recipient developed graft failure or extraintestinal complications (e.g., IBD-related nephritis or arthritis). Conclusion Despite a small sample size, this study's results indicate that the incidence of de novo IBD after KT may be similar to that after LT and higher than that in the general population. Larger studies are required to validate these preliminary findings.
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Affiliation(s)
- Masatomo Ogata
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masaki Kato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takamasa Miyauchi
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Marie Murata-Hasegawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yuko Sakurai
- Division of Pharmacy, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kazunobu Shinoda
- Department of Urology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hajime Yamazaki
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masahiko Yazawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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4
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Hatami B, Pasharavesh L, Sharifian A, Zali MR. Concurrent inflammatory bowel disease and primary sclerosing cholangitis: a review of pre- and post-transplant outcomes and treatment options. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2023; 16:259-269. [PMID: 37767322 PMCID: PMC10520392 DOI: 10.22037/ghfbb.v16i2.2589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/13/2023] [Indexed: 09/29/2023]
Abstract
Primary Sclerosing Cholangitis (PSC) is a chronic cholestatic liver disease which is associated with Inflammatory Bowel Disease (IBD) in 70% of cases. It seems PSC/IBD is a distinct phenotype that is different from PSC, and IBD alone. Hence, we review the epidemiology, pathogenesis, natural course and management of PSC/IBD before and after LT for PSC. Extensive colitis, rectal sparing, backwash ileitis, and mild symptoms are the characteristics of IBD coexisting with PSC. Moreover, PSC patients with concurrent IBD have higher risk of cholangiocarcinoma, and colorectal neoplasia predominantly in right colon and at younger age. Therefore, it is essential to monitor these individuals continuously. It is interesting to note that the course of IBD (ulcerative colitis) after liver transplantation (LT) for PSC varies greatly, and some patients may develop worsening colitis after LT despite immunosuppressive regimens. As well, management of these patients was discussed in this review.
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Affiliation(s)
- Behzad Hatami
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Leila Pasharavesh
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Afsaneh Sharifian
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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5
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Zhou M, Wang D, Li X, Cao Y, Yi C, Wiredu Ocansey DK, Zhou Y, Mao F. Farnesoid-X receptor as a therapeutic target for inflammatory bowel disease and colorectal cancer. Front Pharmacol 2022; 13:1016836. [PMID: 36278234 PMCID: PMC9583386 DOI: 10.3389/fphar.2022.1016836] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/20/2022] [Indexed: 12/09/2022] Open
Abstract
Farnesoid-X receptor (FXR), as a nuclear receptor activated by bile acids, is a vital molecule involved in bile acid metabolism. Due to its expression in immune cells, FXR has a significant effect on the function of immune cells and the release of chemokines when immune cells sense changes in bile acids. In addition to its regulation by ligands, FXR is also controlled by post-translational modification (PTM) activities such as acetylation, SUMOylation, and methylation. Due to the high expression of FXR in the liver and intestine, it significantly influences intestinal homeostasis under the action of enterohepatic circulation. Thus, FXR protects the intestinal barrier, resists bacterial infection, reduces oxidative stress, inhibits inflammatory reactions, and also acts as a tumor suppressor to impair the multiplication and invasion of tumor cells. These potentials provide new perspectives on the treatment of intestinal conditions, including inflammatory bowel disease (IBD) and its associated colorectal cancer (CRC). Moreover, FXR agonists on the market have certain organizational heterogeneity and may be used in combination with other drugs to achieve a greater therapeutic effect. This review summarizes current data on the role of FXR in bile acid metabolism, regulation of immune cells, and effects of the PTM of FXR. The functions of FXR in intestinal homeostasis and potential application in the treatment of IBD and CRC are discussed.
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Affiliation(s)
- Mengjiao Zhou
- Key Laboratory of Medical Science and Laboratory Medicine of Jiangsu Province, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu, China
| | - Danfeng Wang
- Nanjing Jiangning Hospital, Nanjing, Jiangsu, China
| | - Xiang Li
- Key Laboratory of Medical Science and Laboratory Medicine of Jiangsu Province, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu, China
| | - Ying Cao
- Key Laboratory of Medical Science and Laboratory Medicine of Jiangsu Province, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu, China
| | - Chengxue Yi
- School of Medical Technology, Zhenjiang College, Zhenjiang, Jiangsu, China
| | - Dickson Kofi Wiredu Ocansey
- Key Laboratory of Medical Science and Laboratory Medicine of Jiangsu Province, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu, China
- Directorate of University Health Services, University of Cape Coast, Cape Coast, Ghana
| | - Yuling Zhou
- Nanjing Jiangning Hospital, Nanjing, Jiangsu, China
- *Correspondence: Yuling Zhou, ; Fei Mao,
| | - Fei Mao
- Key Laboratory of Medical Science and Laboratory Medicine of Jiangsu Province, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu, China
- *Correspondence: Yuling Zhou, ; Fei Mao,
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6
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Fang JM, Lamps L, Yeboah-Korang A, Cheng J, Westerhoff M. De Novo Inflammatory Bowel Disease Rarely Occurs During Posttransplant Immunosuppression. Am J Clin Pathol 2021; 156:1113-1120. [PMID: 34124746 DOI: 10.1093/ajcp/aqab084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES De novo chronic idiopathic inflammatory bowel disease (CIIBD) is reported to occur at higher rates in posttransplant patients than that of the general population. The previous reports, however, included patients with primary sclerosing cholangitis (PSC), a known association with CIIBD. Hence, we investigated how often posttransplant de novo CIIBD occurs in the absence of PSC. METHODS We identified 185 posttransplant adults without a history of PSC or CIIBD, who had undergone colonoscopy between July 2013 and June 2020. Biopsies were reviewed and clinical data were gathered. RESULTS CIIBD-like colitis accounted for 1.1% (2/185) of our cohort. The 2 affected patients were already taking multiple immunosuppressive therapies. They were initially placed on standard CIIBD maintenance therapy, but then required escalation therapy. One patient had persistent active colitis despite escalation therapy, while the other subsequently had resolution of symptoms and developed quiescent disease. CONCLUSIONS The incidence of CIIBD-like colitis in our study population was lower than what has been previously described. Both patients had a poor response to standard CIIBD therapy, raising the question whether their diagnosis is truly de novo CIIBD or another immunologic process.
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Affiliation(s)
- Jiayun M Fang
- Department of Pathology, Michigan Medicine, Ann Arbor, MI, USA
| | - Laura Lamps
- Department of Pathology, Michigan Medicine, Ann Arbor, MI, USA
| | - Amoah Yeboah-Korang
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Jerome Cheng
- Department of Pathology, Michigan Medicine, Ann Arbor, MI, USA
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KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation 2021; 104:S11-S103. [PMID: 32301874 DOI: 10.1097/tp.0000000000003136] [Citation(s) in RCA: 254] [Impact Index Per Article: 84.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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8
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Zawiasa-Bryszewska A, Brzezińska O, Kurnatowska I, Makowska J. Post-transplant manifestation of ankylosing spondylitis: a case report and review of literature. BMC Nephrol 2021; 22:46. [PMID: 33517879 PMCID: PMC7849111 DOI: 10.1186/s12882-021-02252-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/21/2021] [Indexed: 02/06/2023] Open
Abstract
Background Ankylosing spondylitis (AS) is an insidiously progressive and debilitating form of arthritis involving the axial skeleton, characterized by chronic back pain and progressive spinal stiffness, and lessening of pain and stiffness with exercise. Due to subsequent manifestation in different organs, AS causes reduction in life expectancy, so early diagnosis and treatment are of great importance. No AS cases have been reported in solid-organ transplant recipients yet. Case presentation A 58-year-old woman with end-stage renal disease due to chronic glomerulonephritis, after allogenic kidney transplantation 25 years earlier, with stable, good graft function, treated with chronic immunosuppressive therapy based on cyclosporine A, mycophenolate mofetil, and prednisone, with no previous history of a connective tissue disease presented fever up to 39 °C accompanied by pain localized in sacroiliac region radiating to the left lower limb. Detailed diagnostic procedures and x-rays of the lumbar spine and of the targeted sacroiliac joints revealed lesions characteristic of AS. Sulphasalazine was added to standard immunosuppression regimen with good clinical results. Conclusions We report an adult kidney transplant recipient with a new onset of AS. The risk of relapse or new onset of inflammatory disease in transplant recipients is extremely low due to immunosuppressive therapy following transplantation. However, when it occurs, the clinical presentation is commonly atypical, often leading to delayed diagnosis.
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Affiliation(s)
- Anna Zawiasa-Bryszewska
- Department of Internal Diseases and Transplant Nephrology, The Medical University of Lodz, Lodz, Poland.
| | - Olga Brzezińska
- Department of Rheumatology, The Medical University of Lodz, Lodz, Poland
| | - Ilona Kurnatowska
- Department of Internal Diseases and Transplant Nephrology, The Medical University of Lodz, Lodz, Poland
| | - Joanna Makowska
- Department of Rheumatology, The Medical University of Lodz, Lodz, Poland
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9
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Gioco R, Puzzo L, Patanè M, Corona D, Trama G, Veroux P, Veroux M. Post-transplant colitis after kidney transplantation: clinical, endoscopic and histological features. Aging (Albany NY) 2020; 12:24709-24720. [PMID: 33353887 PMCID: PMC7803550 DOI: 10.18632/aging.202345] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 11/16/2020] [Indexed: 12/19/2022]
Abstract
Chronic immunosuppression may increase the risk of post-transplant infection and medication-related injury and may also be responsible for the increased risk of gastrointestinal complications in kidney transplant recipients. Differentiating the various forms of post-transplant colitis is challenging, since most have similar clinical and histological features. This study evaluated the incidence of post-transplant gastrointestinal complications during screening colonoscopy. Kidney transplant recipients undergoing a colonoscopy for any reasons in the period 2014-2018 were included. Among the 134 patients completing the colonoscopy, 74 patients (56%) had an abnormal finding: an adenoma was found in 25 patients (18.6%), while 19 patients (14.1%) had colitis. Mycophenolic acid/related colitis was the most common colitis (6%), while 7 patients (5.2%) developed a de novo inflammatory bowel disease. Patients with post-transplant colitis were younger and with shorter time from transplant compared to patients without colitis. In conclusions, immunosuppression may predispose kidney transplant recipients to an increased risk of post-transplant colitis. Diagnostic colonoscopy should be encouraged in all transplant patients with refractory diarrhea and gastrointestinal symptoms to allow a prompt diagnosis and a timely treatment, finally improving the quality of life and long-term outcomes of affected patients.
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Affiliation(s)
- Rossella Gioco
- General Surgery Unit, University Hospital of Catania, Catania 95123, Italy
| | - Lidia Puzzo
- Pathology Unit, Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Catania 95123, Italy
| | - Marco Patanè
- Organ Transplant Unit, University Hospital of Catania, Catania 95123, Italy
| | - Daniela Corona
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania 95123, Italy
| | - Giuseppe Trama
- Gastroenterology Unit, University Hospital of Catania, Catania 95123, Italy
| | | | - Massimiliano Veroux
- General Surgery Unit, University Hospital of Catania, Catania 95123, Italy.,Organ Transplant Unit, University Hospital of Catania, Catania 95123, Italy
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10
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Martínez Montiel MDP, Casis Herce B. Inflammatory bowel disease and solid organ transplantation. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:60-64. [PMID: 33233912 DOI: 10.17235/reed.2020.7361/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The population of patients with inflammatory bowel disease (IBD) and solid organ transplant (SOT) is increasing. Two clinical scenarios exist, recurrence of pre-existing IBD, which is more common, and de novo development of IBD, with a much higher incidence than in the general population. Their clinical course differs and may have a negative impact on the graft in both cases. The pathophysiological mechanisms remain unknown and no specific treatment recommendations are available. The combined effect of biologic therapy against IBD and immunosuppressive therapy against a potential rejection means that close monitoring is mandatory to identify infection, autoimmune events and malignancies. The colorectal cancer (CRC) rate is higher in this population. The group at greatest risk are patients with IBD undergoing liver transplantation (LT) for primary sclerosing cholangitis (PSC).
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11
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Gioco R, Corona D, Ekser B, Puzzo L, Inserra G, Pinto F, Schipa C, Privitera F, Veroux P, Veroux M. Gastrointestinal complications after kidney transplantation. World J Gastroenterol 2020; 26:5797-5811. [PMID: 33132635 PMCID: PMC7579754 DOI: 10.3748/wjg.v26.i38.5797] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/28/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal complications are common after renal transplantation, and they have a wide clinical spectrum, varying from diarrhoea to post-transplant inflammatory bowel disease (IBD). Chronic immunosuppression may increase the risk of post-transplant infection and medication-related injury and may also be responsible for IBD in kidney transplant re-cipients despite immunosuppression. Differentiating the various forms of post-transplant colitis is challenging, since most have similar clinical and histological features. Drug-related colitis are the most frequently encountered colitis after kidney transplantation, particularly those related to the chronic use of mycophenolate mofetil, while de novo IBDs are quite rare. This review will explore colitis after kidney transplantation, with a particular focus on different clinical and histological features, attempting to clearly identify the right treatment, thereby improving the final outcome of patients.
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Affiliation(s)
- Rossella Gioco
- General Surgery Unit, University Hospital of Catania, Catania 95123, Italy
| | - Daniela Corona
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania 95123, Italy
| | - Burcin Ekser
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, United States
| | - Lidia Puzzo
- Pathology Unit, Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Catania 95123, Italy
| | - Gaetano Inserra
- Gastroenterology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania 95100, Italy
| | - Flavia Pinto
- General Surgery Unit, University Hospital of Catania, Catania 95123, Italy
| | - Chiara Schipa
- General Surgery Unit, University Hospital of Catania, Catania 95123, Italy
| | | | | | - Massimiliano Veroux
- General Surgery Unit, Organ Transplant Unit, University Hospital of Catania, Catania 95123, Italy
- Department of Medical and Surgical Sciences and Advanced Technologies, University Hospital of Catania, Catania 95123, Italy
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12
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Kobiela J, Dobrzycka M, Danielewicz R, Jończyk J, Łachiński AJ, Śledziński Z, Dębska-Ślizień A. Colonoscopy as Part of Pre-Transplant Work-Up in Successful Kidney Transplant Candidates: Single-Center Experience and Review of Literature. Ann Transplant 2018; 23:782-788. [PMID: 30409961 PMCID: PMC6247820 DOI: 10.12659/aot.910658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Screening colonoscopy is not obligatory in kidney pre-transplant work-up guidelines. According to recommendations, only transplant recipients over age 50 years should be screened. The aim of this study was to characterize endoscopic findings revealed as part of pre-transplant work-up. Material/Methods We retrospectively reviewed pre-transplant work-up charts of 434 adult patients who received a cadaveric donor kidney transplantation (KT) from 2012 to 2015. Endoscopic findings analysis with age subgroup (<50 and ≥50) analysis were performed. Results Out of 434 of patients that underwent KT, 29% have had a colonoscopy. In 75.6% of those, pathologies were found. Hemorrhoids were found in 33% and polyps in 30.7% of patients. Adenoma detection rate (ADR) was 18.1% (67.5% distal predominance). Advanced ADR was 10.2% (distal predominance). Diverticulosis was found in 28.3% of patients and ulcerative colitis was found in 2.4%. In age subgroup analysis, ADR was higher in patients ≥50 years compared to those <50 years (21.6% vs. 4%; p=0.041). Conclusions Colonoscopy as part of pre-transplant work-up enables removal of precancerous lesions and management of benign findings. All candidates meeting criteria for the general population should be screened. Patients under age 50 years could also benefit from colonoscopy as part of the pre-transplant work-up. Therefore, we suggest that baseline colonoscopy should be included in pre-transplant work-up guidelines for all patients, regardless of age. However, further studies are needed to confirm this recommendation.
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Affiliation(s)
- Jarek Kobiela
- Department of General, Endocrine, and Transplant Surgery, Medical University of Gdańsk, Gdańsk, Poland
| | - Małgorzata Dobrzycka
- Department of General, Endocrine, and Transplant Surgery, Medical University of Gdańsk, Gdańsk, Poland
| | - Roman Danielewicz
- Department of Surgical and Transplant Nursing, Medical University of Warsaw, Warsaw, Poland
| | - Justyna Jończyk
- Department of General, Endocrine, and Transplant Surgery, Medical University of Gdańsk, Gdańsk, Poland
| | - Andrzej J Łachiński
- Department of General, Endocrine, and Transplant Surgery, Medical University of Gdańsk, Gdańsk, Poland
| | - Zbigniew Śledziński
- Department of General, Endocrine, and Transplant Surgery, Medical University of Gdańsk, Gdańsk, Poland
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
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13
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Buchholz BM, Lykoudis PM, Ravikumar R, Pollok JM, Fusai GK. Role of colectomy in preventing recurrent primary sclerosing cholangitis in liver transplant recipients. World J Gastroenterol 2018; 24:3171-3180. [PMID: 30065563 PMCID: PMC6064960 DOI: 10.3748/wjg.v24.i28.3171] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/08/2018] [Accepted: 07/16/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To study the published evidence on the impact of colectomy in preventing recurrent primary sclerosing cholangitis (rPSC).
METHODS An unrestricted systematic literature search in PubMed, EMBASE, Medline OvidSP, ISI Web of Science, Lista (EBSCO) and the Cochrane library was performed on clinical studies investigating colectomy in liver transplantation (LT) recipients with and without rPSC in the liver allograft. Study quality was evaluated according to a modification of the methodological index for non-randomized studies (MINORS) criteria. Primary endpoints were the impact of presence, timing and type of colectomy on rPSC. Overall presence of inflammatory bowel disease (IBD), time of IBD diagnosis, posttransplant IBD and immunosuppressive regimen were investigated as secondary outcome.
RESULTS The literature search yielded a total of 180 publications. No randomized controlled trial was identified. Six retrospective studies met the inclusion criteria of which 5 studies were graded as high quality articles. Reporting of IBD was heterogenous but in four publications, either inflammatory bowel disease, ulcerative colitis or in particular active colitis post-LT significantly increased the risk of rPSC. The presence of an intact (i.e., retained) colon at LT was identified as risk factor for rPSC in two of the high quality studies while four studies found no effect. Type of colectomy was not associated with rPSC but this endpoint was underreported (only in 33% of included studies). Neither tacrolimus nor cyclosporine A yielded a significant benefit in disease recurrence of primary sclerosing cholangitis (PSC).
CONCLUSION The data favours a protective role of pre-/peri-LT colectomy in rPSC but the current evidence is not strong enough to recommend routine colectomy for rPSC prevention.
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Affiliation(s)
- Bettina M Buchholz
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital London, London NW32QG, United Kingdom
| | - Panagis M Lykoudis
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital London, London NW32QG, United Kingdom
| | - Reena Ravikumar
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital London, London NW32QG, United Kingdom
| | - Joerg M Pollok
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital London, London NW32QG, United Kingdom
| | - Giuseppe K Fusai
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital London, London NW32QG, United Kingdom
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14
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The gastroenterologist's guide to management of the post-liver transplant patient. Am J Gastroenterol 2018; 113:819-828. [PMID: 29748558 DOI: 10.1038/s41395-018-0049-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/11/2018] [Indexed: 12/11/2022]
Abstract
The management of the post-liver transplant patient is complex and involves a large interdisciplinary team. After referral to a transplant center, evaluation and listing, and eventual transplantation, the patient is cared for closely by the transplant center. Once deemed ready for discharge, the patient returns to the primary care provider for ongoing management of the various issues that increase in incidence post transplant such as osteoporosis, cardiovascular, and renal diseases, as well as metabolic syndrome. The role of the gastroenterologist is not well defined, but certainly, he or she may be called upon for the initial evaluation and ongoing management of gastrointestinal as well as hepatobiliary issues. This includes but is not limited to the investigation of abnormal liver tests, non-specific gastrointestinal complaints such as nausea, vomiting, or diarrhea, biliary complications, and even recurrent hepatic disease. Having familiarity with post-transplant immunosuppressive agents, drug interactions, and potential infectious and malignancy-related complications of transplant is essential, as the primary gastroenterologist may be expected in some situations to field the initial work-up, if patient access to the transplant center is limited. The aim of this review is to summarize the gastroenterologist's role in the management of the post-liver transplant patient.
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15
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Mouchli MA, Singh S, Boardman L, Bruining DH, Lightner AL, Rosen CB, Heimbach JK, Hasan B, Poterucha JJ, Watt KD, Kane SV, Raffals LE, Loftus EV. Natural History of Established and De Novo Inflammatory Bowel Disease After Liver Transplantation for Primary Sclerosing Cholangitis. Inflamm Bowel Dis 2018; 24. [PMID: 29522202 PMCID: PMC6085995 DOI: 10.1093/ibd/izx096] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The course of inflammatory bowel disease (IBD) after liver transplantation (LT) for primary sclerosing cholangitis (PSC) is poorly understood. We describe the natural history of established IBD after LT (including risk of disease progression, colectomy, and neoplasia) and de novo IBD. METHODS In a retrospective cohort, we identified all patients with PSC who underwent LT for advanced PSC at Mayo Clinic, Rochester, Minnesota. Risk factors were identified using multivariate Cox proportional hazard analysis. RESULTS Three hundred seventy-three patients were identified (mean age, 47.5 ± 11.7 years; 64.9% male). Over a median (range) of 10 (5.5-17.1) years, 151 patients with PSC-IBD with an intact colon at the time of LT were studied. Post-LT, despite transplant-related immunosuppression, 56/151 (37.1%) required escalation of therapy, whereas 87 had a stable course (57.6%) and 8 patients (5.3%) improved. The 1-, 5-, and 10-year risks of progression of IBD were 4.0%, 18.5%, and 25.5%, respectively. On multivariate analysis, tacrolimus-based immunosuppression post-LT were associated with unfavorable course, and azathioprine use after LT was associated with improved course post-LT. Of 84 patients with no evidence of IBD at the time of LT, 22 (26.2%) developed de novo IBD post-LT. The 1-, 5-, and 10-year cumulative incidences of de novo IBD were 5.5%, 20.0%, and 25.4%, respectively. On univariate analysis, mycophenolate mofetil use after LT was associated with increased risk of de novo IBD, but azathioprine use after LT seemed to be protective. CONCLUSIONS The 10-year cumulative probability of IBD flare requiring escalation of therapy after LT for PSC was 25.5%, despite immunosuppression for LT. The 10-year cumulative risk of de novo IBD after LT for PSC was 25.4%. Transplant-related immunosuppression may modify the risk of de novo IBD, with an increased risk with mycophenolate and a decreased risk with azathioprine. 10.1093/ibd/izx096_video1izx096.video15746673864001.
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Affiliation(s)
- Mohamad A Mouchli
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota,Division of Gastroenterology and Hepatology, Carilion Clinic, Roanoke, Virginia
| | - Siddharth Singh
- Division of Gastroenterology, Department of Internal Medicine, UCSD, La Jolla, California
| | - Lisa Boardman
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Charles B Rosen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Julie K Heimbach
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Bashar Hasan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John J Poterucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota,Address correspondence to: Edward V. Loftus, Jr., MD, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905 ()
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16
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Abstract
Inflammatory bowel disease following a solid organ transplantation while the patient is receiving immunosuppressive therapy is a rare phenomenon. Here we present a 48-year-old man who underwent cardiac transplantation 9 years earlier and was receiving cyclosporine as immunosuppressive therapy since then, presenting with complaints of rectorrhagia and diarrhea. In follow-up, he was diagnosed as having ulcerative colitis. We also reviewed the literature for similar cases, which yielded very few similar ones.
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Affiliation(s)
- Anahita Sadeghi
- Digestive Disease Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Pouya Bastani
- Department of Internal Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Mohamadnejad
- Liver and Pancreatobiliary Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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17
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Differentiating Posttransplant Inflammatory Bowel Disease and Other Colitides in Renal Transplant Patients. Am J Surg Pathol 2017; 41:1666-1674. [PMID: 28786879 DOI: 10.1097/pas.0000000000000921] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Renal transplant recipients who present with gastrointestinal complaints may have symptoms related to their underlying renal disease or secondary to their immunosuppressive regimen. Immunosuppression increases patients' risk for infection and medication-induced injury, and a subset of transplant patients develop a form of inflammatory bowel disease (IBD) despite being immunosuppressed. In this study, we present the spectrum of changes in colonic biopsy histology that occur in the postrenal transplant population, with emphasis on the clinical and histologic features that may allow distinction between several common disorders. Over a 15-year period, 51 postrenal transplant patients underwent colonoscopy with biopsy. Eleven (22%) patients had infectious colitis, and 10 of these had biopsy proven acute colitis. Another 17 (33%) patients were determined to have a medication-related injury based on resolution of symptoms following drug cessation. The majority (53%) of these colonic biopsies demonstrated crypt epithelial cell apoptosis and/or architectural distortion, although 41% were histologically normal. Four (8%) patients were ultimately diagnosed with a form of IBD after exclusion of other etiologies; biopsies from these patients demonstrated chronic active colitis or enteritis with plasma cell-rich expansion of the lamina propria and basal lymphoplasmacytosis. The increased prevalence of IBD in this patient cohort (4/700) compared with that reported in the overall North American population (1 to 2/700) is in line with prior studies and is likely related to the therapeutic regimen and associated immune dysregulation that occurs in solid-organ transplant recipients. We demonstrate that a combination of clinical, endoscopic, and histologic features are useful to distinguish among causes of gastrointestinal symptoms in this high risk population.
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18
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Shaikh SA, Fitzgerald L, Tischer S. Safety and Efficacy of Biologic Agents for the Management of Inflammatory Bowel Disease After Liver Transplantation. Pharmacotherapy 2017; 37:1578-1585. [PMID: 28960437 DOI: 10.1002/phar.2036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Primary sclerosing cholangitis (PSC) frequently progresses to end-stage liver disease and cirrhosis, requiring liver transplantation. Approximately 70% of patients with PSC have concomitant inflammatory bowel disease (IBD) during their clinical course. After liver transplantation for PSC, corticosteroids and other high-intensity immunosuppressants are initiated to keep IBD in remission. Patients with IBD that is refractory to these agents may need to be managed with biologic therapies. Biologic agents, however, may further increase the risks for malignancy and infection due to their immunosuppressive effects. Thus, to gain a better understanding of the risks and benefits of these agents in this high-risk patient population, we performed a literature search of the PubMed database (2002-2017) to identify studies assessing the efficacy and safety of various biologic agents for the management of IBD in liver transplant recipients. No randomized controlled studies or retrospective comparative studies were identified; however, 15 case reports and case series were identified that met our inclusion criteria. From these case reports, we identified 67 patients who developed de novo or recurrent IBD after liver transplantation and received anti-tumor necrosis factor-α or anti-integrin therapy. Of the 13 published cases reporting clinical response or remission of IBD activity in liver transplant recipients (59 patients), clinical response or remission of IBD was reported in 38 (64.4%) of those patients. Adverse complications reported included cholangitis, oral candidiasis, Clostridium difficile colitis, bacterial pneumonia, cryptosporidiosis, Epstein-Barr virus-positive posttransplantation lymphoproliferative disease, and hepatotoxicity. Given the limited literature (case reports and case series) highlighted in this review, biologic agents such as tumor necrosis factor-α inhibitors and integrin inhibitors commonly used for moderate to severe IBD may be appropriate after liver transplantation; however, consideration of risk versus benefit should always occur in a patient-specific manner.
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Affiliation(s)
- Suhail A Shaikh
- Department of Pharmacy Services and Clinical Sciences, University of Michigan Health System, Ann Arbor, Michigan
| | - Linda Fitzgerald
- Department of Pharmacy Services and Clinical Sciences, University of Michigan Health System, Ann Arbor, Michigan
| | - Sarah Tischer
- Department of Pharmacy Services and Clinical Sciences, University of Michigan Health System, Ann Arbor, Michigan
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19
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Abstract
Inflammatory bowel disease (IBD) after solid organ transplantation is rare. We report new-onset Crohn’s disease successfully treated with anti-tnfα therapy in a cardiac transplantation recipient. Our case highlights the importance of including IBD in the differential of chronic diarrhea despite significant immunosuppression and suggests that anti-tnf alpha therapy is effective in post-transplant IBD.
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20
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Filipec Kanizaj T, Mijic M. Inflammatory bowel disease in liver transplanted patients. World J Gastroenterol 2017; 23:3214-3227. [PMID: 28566881 PMCID: PMC5434427 DOI: 10.3748/wjg.v23.i18.3214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/13/2017] [Accepted: 04/21/2017] [Indexed: 02/06/2023] Open
Abstract
Most common hepatobiliary manifestation of inflammatory bowel disease (IBD) are primary sclerosing cholangitis (PSC) and autoimmune hepatitis, ranking them as the main cause of liver transplantation (LT) in IBD setting. Course of pre-existing IBD after LT differs depending on many transplant related factors. Potential risk factors related to IBD deterioration after LT are tacrolimus-based immunosuppressive regimens, active IBD and cessation of 5-aminosalicylates at the time of LT. About 30% patients experience improvement of IBD after LT, while approximately the same percentage of patients worsens. Occurrence of de novo IBD may develop in 14%-30% of patients with PSC. Recommended IBD therapy after LT is equivalent to recommendations to overall IBD patients. Anti-tumor necrosis factor alpha appears to be efficient for refractory IBD. Due to potential side effects it needs to be applied with caution. In average 9% of patients require proctocolectomy due to medically refractory IBD or colorectal carcinoma. The most frequent complication in patients who undergo proctocolectomy with ileal-pouch anal anastomosis is pouchitis. It is still undeterminable if LT adds to risk of developing pouchitis in PSC patients. Annual colonoscopies are recommended as surveillance and precaution of colonic malignancies.
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21
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Increased Risk of Oral Cancer in Patients With Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2016; 14:413-20. [PMID: 26499929 DOI: 10.1016/j.cgh.2015.09.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 09/29/2015] [Accepted: 09/30/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Epidemiology studies have consistently found an increased risk of oral malignancies in organ transplant recipients, patients with graft-versus-host disease, and people with human immunodeficiency virus infection. We assessed the risk of oral cancer in patients with inflammatory bowel diseases (IBD). METHODS We collected data on 7294 patients with IBD (3785 women) seen at Mount Sinai Medical Center, New York, from 2000 through 2011. The expected incidence of oral cancer was calculated for each sex-specific and 5-year age-specific stratum by specific incidence rates using the Surveillance, Epidemiology and End Results 18 registry data (2000-2011), adjusted for age to the 2000 United States population (census P25-1130). RESULTS Eleven patients (7 men) were found to have biopsy-proven oral cancer. Six patients had cancer of the tongue; 2 patients had cancer of the hard palate; and the remaining 3 had tonsillar, buccal, or mandibular sarcoma. Before the cancer diagnosis, IBD had been treated in 4 patients with azathioprine or mercaptopurine, in 1 patient with infliximab, and 3 in patients with combination of biologic agents and azathioprine; 4 of the patients had not been treated for IBD. The age- and sex-adjusted standardized incidence ratio (SIR) for oral cancer in patients with IBD was 9.77 (95% confidence interval [CI], 5.14-16.98). In women, the SIR was 12.07 (95% CI, 3.84-29.11), and in men the SIR was 8.49 (95% CI, 3.71-16.78). The age-adjusted SIR for tongue cancer was 18.91 (95% CI, 7.66-39.33): 17.06 for men (95% CI, 5.42-41.15) and 22.10 for women (95% CI, 3.70-73.01). CONCLUSIONS We found patients with IBD to be at increased risk for oral cancers, especially tongue cancer. Women are at higher risk than men.
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22
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Meszaros M, Pageaux GP, Altwegg R. Management of Ulcerative Colitis Using Vedolizumab After Liver Transplantation for Primary Sclerosing Cholangitis. J Crohns Colitis 2016; 10:236. [PMID: 26449788 DOI: 10.1093/ecco-jcc/jjv182] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 09/30/2015] [Indexed: 02/08/2023]
Affiliation(s)
- Magdalena Meszaros
- Unité de Transplantation Hépatique, Pôle Digestif, CHU Saint-Eloi, Montpellier, France
| | - Georges-Philippe Pageaux
- Unité de Transplantation Hépatique, Pôle Digestif, CHU Saint-Eloi, Montpellier, France Département de transplantation hépatique, Université Montpellier I, Montpellier, France
| | - Romain Altwegg
- Unité de Transplantation Hépatique, Pôle Digestif, CHU Saint-Eloi, Montpellier, France Département de transplantation hépatique, Université Montpellier I, Montpellier, France
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23
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Puri K, Kocoshis S, Risma K, Perez L, Hart C, Chin C, Ryan TD, Jefferies JL, Schumacher KR, Castleberry C. Basiliximab treatment for autoimmune bowel disease in a pediatric heart transplant patient. Pediatr Transplant 2015; 19:E165-9. [PMID: 26374667 PMCID: PMC8215525 DOI: 10.1111/petr.12584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2015] [Indexed: 01/09/2023]
Abstract
Autoimmune-mediated bowel disease has been reported after pediatric heart transplantation. Recognition and treatment of these patients has been difficult. We describe a patient who responded to steroids and basiliximab therapy after an inflammatory process secondary to abnormal T-cell activation. Our patient is a 28-month-old female who received a heart transplant at five wk of age. At 24 months post-transplant, she developed fever and bloody stools. Initial investigations were significant for an elevated ESR (>120) and CRP (15.2). Symptoms persisted despite bowel rest and mycophenolate discontinuation. Endoscopic evaluation revealed discontinuous ulcerative disease involving esophagus, terminal ileum, right and left colon, necessitating extensive bowel resection. She had additional airway inflammation leading to a TEF at the site of esophageal ulceration, requiring tracheostomy. Immune evaluation revealed autoimmune dysregulation that responded to parenteral methylprednisolone. Chronic basiliximab therapy allowed for successful weaning of steroids with sustained remission. She has been transitioned to sirolimus and tacrolimus maintenance immunosuppression with plans to discontinue basiliximab once off steroids. In conclusion, bowel disease in the setting of pediatric heart transplantation can be severe and refractory to traditional treatment methods. Tailoring immune therapy to activated T cells can result in remission. Basiliximab therapy was used in our patient to maintain steroid-induced remission, but long-term complications of this disease process are unknown.
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Affiliation(s)
- K. Puri
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - S. Kocoshis
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - K. Risma
- Allergy and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - L. Perez
- Allergy and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - C. Hart
- Otolaryngology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - C. Chin
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - T. D. Ryan
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - J. L. Jefferies
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - K. R. Schumacher
- Pediatric Cardiology, CS Mott Children’s Hospital, Ann Arbor, MI, USA
| | - C. Castleberry
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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24
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Tinoco R, García E, Ramírez F, Correro F, Vega V. [A case of de novo inflammatory bowel disease after liver transplantation for cryptogenic cirrhosis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 39:458-60. [PMID: 26321322 DOI: 10.1016/j.gastrohep.2015.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 07/02/2015] [Accepted: 07/08/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Raquel Tinoco
- Servicio de Medicina Interna, Hospital Universitario de Puerto Real, Puerto Real, Cádiz, España
| | - Encarnación García
- Servicio de Aparato Digestivo, Hospital Universitario de Puerto Real, Puerto Real, Cádiz, España
| | - Francisco Ramírez
- Servicio de Aparato Digestivo, Hospital Universitario de Puerto Real, Puerto Real, Cádiz, España.
| | - Francisco Correro
- Servicio de Aparato Digestivo, Hospital Universitario de Puerto Real, Puerto Real, Cádiz, España
| | - Vicente Vega
- Servicio de Cirugía General, Hospital Universitario de Puerto Real, Puerto Real, Cádiz, España
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25
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Solid Organ Transplantation in Patients with Inflammatory Bowel Diseases (IBD): Analysis of Transplantation Outcome and IBD Activity in a Large Single Center Cohort. PLoS One 2015; 10:e0135807. [PMID: 26288187 PMCID: PMC4545391 DOI: 10.1371/journal.pone.0135807] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 07/27/2015] [Indexed: 12/12/2022] Open
Abstract
Background Currently, limited data of the outcome of inflammatory bowel disease (IBD) in patients after solid organ transplantation (SOT) are available. We aimed to analyze effects of SOT on the IBD course in a large IBD patient cohort. Methods Clinical data from 1537 IBD patients were analyzed for patients who underwent SOT (n = 31) between July 2002 and May 2014. Sub-analyses included SOT outcome parameters, IBD activity before and after SOT, and efficacy of IBD treatment. Results 4.74% of patients with ulcerative colitis (UC) and 0.84% of patients with Crohn’s disease (CD) underwent SOT (p = 2.69 x 10−6, UC vs. CD). 77.4% of patients with SOT underwent liver transplantation (LTx) with tacrolimus-based immunosuppressive therapy after SOT. All LTx were due to primary sclerosing cholangitis (PSC) or PSC overlap syndromes. Six patients (19.4%) required renal transplantation and one patient (3.2%) heart transplantation. A survival rate of 83.9% after a median follow-up period of 103 months was observed. Before SOT, 65.0% of patients were in clinical remission and 5 patients received immunosuppressive therapy (16.1%). After SOT, 61.0% of patients were in remission (p = 1.00 vs. before SOT) and 29.0% required IBD-specific immunosuppressive or anti-TNF therapy (p = 0.54 vs. before SOT). 42.9% of patients with worsening of IBD after SOT were at higher risk of needing steroid therapy for increased IBD activity (p = 0.03; relative risk (RR): 10.29; 95% CI 1.26–84.06). Four patients (13.0%) needed anti-TNF therapy after SOT (response rate 75%). Conclusions SOT was more common in UC patients due to the higher prevalence of PSC-related liver cirrhosis in UC. Despite mainly tacrolimus-based immunosuppressive regimens, outcome of SOT and IBD was excellent in this cohort. In this SOT cohort, concomitant immunosuppressive therapy due to IBD was well tolerated.
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26
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Schöning W, Schmeding M, Ulmer F, Andert A, Neumann U. Liver Transplantation for Patients with Cholestatic Liver Diseases. VISZERALMEDIZIN 2015; 31:194-8. [PMID: 26468315 PMCID: PMC4569198 DOI: 10.1159/000431017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Cholestatic liver diseases (CD) account for 11% of all liver transplantations (LT) in the Eurotransplant region. Despite the excellent long-term outcome that is considerably superior to all other indications for LT, transplant surgeons and physicians face nowadays – in the era of MELD (Model of End-Stage Liver Disease)-based allocation, organ shortage, and extended allocation policies – more and more challenges in this patient cohort, especially since there is no curative medical treatment for these entities. Methods Based on a literature review and personal experience in liver transplantation for CD, we show the status quo of indication, allocation, and outcome as well as potential strategies to overcome long waiting times and organ shortage. Results Concerning graft and patient survival, CD remain the ‘best indications’ for LT. Since the implementation of MELD-based allocation results in patients with primary sclerosing cholangitis (PSC) could be preserved on good levels only by the implementation and revision of standard exceptions. Recurrence of PSC after LT remains a challenge for transplant surgeons and physicians. New data has kindled a debate on biliary reconstruction in LT for PSC. Promising data on living donor LT motivate to push the boundaries in this direction. Conclusion CD are excellent indications for liver transplantation since excellent long-term outcomes are achievable when the transplant is performed at the right time. The decisions concerning evaluation, listing, and allocation should be made by an interdisciplinary team of gastroenterologists and transplant surgeons.
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Affiliation(s)
- Wenzel Schöning
- General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Maximilian Schmeding
- General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Florian Ulmer
- General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Anne Andert
- General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf Neumann
- General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
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