Epstein-Barr virus associated colitis in kidney transplant patients: a case series

BACKGROUND

Gastrointestinal complications are common in kidney transplant (KT) patients and can be a consequence of the chronic use of immunosuppression. The differential diagnosis of colitis in KT patients includes intolerance to immunosuppressive agents, namely mycophenolate mofetil, de novo inflammatory bowel disease (IBD) and opportunistic infections. Epstein-Barr virus (EBV) infection may cause post-transplant colitis or trigger de novo IBD, although is seldom thought as the causative pathogen.

OBJECTIVES

To describe clinical characteristics, endoscopic and histological findings, treatment and outcome of three patients that developed EBV associated colitis following kidney transplantation.

METHODS

We retrospectively analyzed three patients with EBV associated colitis; clinical data including transplantation, gastrointestinal symptoms, endoscopy findings, and follow-up data was obtained.

RESULTS

We present a case series of three patients with EBV colitis following KT, with an average age at clinical presentation of 59 years and elapsed time since the KT ranging from five to 22 years. Clinical manifestations included bloody diarrhoea, abdominal pain, weight loss and/or fever. Cytomegalovirus colitis, mycophenolate mofetil-related colitis, lymphoproliferative disease and graft versus host disease were excluded. One patient had a prior diagnosis of IBD. Two of the three patients had an unfavourable outcome with death despite reduction and/or switching of immunosuppressants, optimal medical treatment (including antiviral and intravenous immunoglobulin therapies) and salvage surgical therapy.

CONCLUSION

A multidisciplinary approach is necessary to allow an expeditious diagnosis of a rare entity such as EBV associated colitis in KT. Long-term surveillance of these patients and the development of effective and safe therapies is essential.

MO691: Risk Factors Associated with Cognitive Dysfunction in Peritoneal Dialysis

BACKGROUND AND AIMS

Cognitive dysfunction (CD) in peritoneal dialysis (PD) patients has been increasingly described as a risk factor for worse outcomes such as peritonitis, technique failure and mortality. Identification of these patients and associated risk factors is of most importance to mitigate these consequences. In this study our aims were: (i) to determine the presence of CD in a population of PD patients and (ii) to identify possible risk factors associated with CD.

METHOD

We performed an observational, cross-sectional study to evaluate cognitive function using the Montreal cognitive assessment (MOCA) test and mini mental state (MMS) test in 56 PD patients at our program whenever they were present in a schedule PD appointment. Patients with diagnosis of dementia or severe neurological impairment, active cancer or active infection were excluded. Demographic variables, comorbidities, peritonitis and exit-site infections episodes, laboratory data and dialysis adequacy were retrospectively collected in a 3-month period.

RESULTS

We evaluated 56 patients with a median age of 65 years (IQR 25.5); 53.6% were male. About 73.2% of our patients had a lower level of education; 64.3% were not professionally active; 16.1% lived alone and 25.0% needed help to perform PD treatment. Charlson comorbidity index (CCI) median score was 5 (IQR 2). Most prevalent comorbidities were hypertension (85.7%), cardiovascular disease (37.5%), diabetes (37.5%) and peripheral arterial disease (PAD) (21.4%). PD therapy median duration was 20 months (IQR 24). Automated PD was the most common modality (60.7%). Episodes of peritonitis and exit-site infection were detected in 10.7% and 3.6% of patients, respectively.

CD assessed by MOCA test was present in 64.3% of patients, with a median score of 21.5 (IQR 5.5). Visuospatial/executive, naming, attention, language, abstraction and delayed recall areas were impaired in this population (P < 0.05).

Possible predictors of CD with MOCA test (Mann–Whitney or Qui square) were: higher age (P = 0.0001); lower level of education (P = 0.003); not professionally active (P = 0.004); need of a helper (P = 0.014); continuous ambulatory PD modality (P = 0.004). Higher CCI score (P = 0.0003), cardiovascular disease (P = 0.061) and PAD (P = 0.024) were also associated with CD. Lower levels of urea (P = 0.022) and Kt/V (P = 0.031) and higher levels of bicarbonate (P = 0.040), all related to CD. Multivariable analysis showed that lower Kt/V was the most relevant factor related to CD (P = 0.006).

CD assessed by MMS test was present in 33.9% of patients, with a median score of 23 (IQR 5). Impairment of all areas evaluated were observed namely orientation, immediate and delayed recall, attention and calculation, language and visuospatial (P < 0.05). Again, predictors of CD were higher age (P = 0.044); very low level of education (P = 0.024); need of a helper (P = 0.004). Higher CCI score (P = 0.001), diabetes (P = 0.018) and PAD (P = 0.012) were also associated with CD. Multivariate analysis showed that higher CCI score was the most relevant factor related to CD (P = 0.02).

CONCLUSION

CD in our PD population was present in 64.3% of patients with MOCA test and 33.9% of patients with MMS test, with similar results to those described in the current literature. Patients with CD had impairment of multiple areas of cognition, such as visuospatial, memory, attention and language. Higher age, lower level of education, and need of a helper were risk factors identified for CD. Patients with CD also have a higher load of vascular diseases. Patients with lower Kt/V levels presented more CD detected by MOCA test, which can be associated with a lower clearance of possible toxins that contribute to CD; however, larger studies have to be done to confirm this hypothesis.