Abstract
Diarrhoea in transplantation may be secondary to infectious agents and immunosuppressive drugs. The use of combined immunosuppressive drugs increases the incidence of infectious diarrhoea. We retrospectively collected all diarrhoea episodes during a 3-year period in 199 pediatric renal transplant recipients, including 47 patients receiving a kidney transplant during this period. We diagnosed 64 diarrhoea episodes (32% of the patients, 10.7% per year). Fourteen diarrhoea episodes could be attributed to the immunosuppressive treatment, and 12 remained without diagnosis. Nineteen patients (<10%) receiving mycophenolic acid (MPA) developed diarrhoea, 14 of whom had episodes attributable to the immunosuppressive treatment. Reducing the MPA dose or switching to another immunosuppressant did not induce graft rejection, if at all, for at least 6 months. Thirty-eight diarrhoea episodes were caused by infectious agents: viruses in 16 patients, bacterial agents in ten patients, Candida albicans in four cases and parasitic agents in eight cases (Giardia lambdia in one patient and Cryptosporidium in seven patients). In our cohort, Cryptosporidium was responsible for 18% of the infectious diarrhoea and 11% of all causes of diarrhoea, and it affected 3.5% of the newly transplanted patients during the 3-year study period. The clinical presentation of the disease was profuse and persistent diarrhoea with acute renal failure in all patients. We propose that oocysts be screened for in the stool during the early stages of tests for determining the origin of infectious diarrhoea. Disease treatment requires early specific treatment (nitazoxanide) for extended periods of time in conjunction with supportive rehydration.
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References
Arslan H, Inci EK, Azap OK, Karakayali H, Torgay A, Haberal M (2007) Etiologic agents of diarrhea in solid organ recipients. Transpl Infect Dis 9:270–275
Maes B, Hadaya K, de Moor B, Cambier P, Peeters P, de Meester J, Donck J, Sennesael J, Squifflet J-P (2006) Severe diarrhea in renal transplant patients: Results or the DIDACT Study. Am J Transplant 6:1466–1472
Rubin RH (2001) Gastrointestinal infectious disease complications following transplantation and their differentiation from immunosuppressant-induced gastrointestinal toxicities. Clin Transplant 15:11–22
Veroux M, Puzzo L, Corona D, Buffone A, Tallarita T, Murabito P, Veroux P (2007) Cytomegalovirus and Clostridium difficile ischemic colitis in a renal transplant recipient: a lethal complication of anti-rejection therapy? Urol Int 79:177–179
Keven K, Basu A, Re L, Tan H, Marcos A, Fung JJ, Starzl TE, Simmons RL, Shapiro R (2004) Clostridium difficile colitis in patients after kidney and pancreas-kidney transplantation. Transpl Infect Dis 6:10–14
Ok UZ, Cirit M, Uner A, Ok E, Akçiçek F, Basçi A, Ozcel MA (1997) Cryptosporidiosis and blastocystosis in renal transplant recipients. Nephron 75:171–174
Dillingham RA, Lima AA, Guerrant RL (2002) Cryptosporidiosis: epidemiology and impact. Microbes Infect 4:1059–1066
Burdese M, Veglio V, Consiglio V, Soragna G, Mezza E, Bergamo D, Tattoli F, Rossetti M, Jeantet A, Segoloni GP, Piccoli GB (2005) A dance teacher with kidney–pancreas transplant and diarrhoea: what is the cause? Nephrol Dial Transplant 20:1759–1761
Chappell CL, Okhuysen PC (2002) Cryptosporidiosis. Curr Opin Infect Dis 15:523–527
Hunter PR, Nichols G (2002) Epidemiology and clinical features of Cryptosporidium infection in immunocompromised patients. Clin Microbiol Rev 15:145–154
Hoepelman AI (1996) Current therapeutic approaches to cryptosporidiosis in immunocompromised patients. J Antimicrob Chemother 37:872–880
Udgiri N, Minz M, Kashyap R, Heer M, Gupta CS, Mohandas K, Minz RW, Malla N (2004) Intestinal cryptosporidiosis in living related renal transplant recipients. Transplant Proc 36:2128–2129
Hong DK, Wong CJ, Gutierrez K (2007) Severe cryptosporidiosis in a seven-year-old renal transplant recipient—case report and review of the literature. Pediatr Transplant 11:94–100
Gerber DA, Green M, Jaffe R, Greenberg D, Mazariegos G, Reyes J (2000) Cryptosporidial infections after solid organ transplantation in children. Pediatr Transplant 4:50–55
Ekberg H, Kyllönen L, Madsen S, Grave G, Solbu D, Holdaas H (2007) Increased prevalence of gastrointestinal symptoms associated with impaired quality of life in renal transplant recipients. Transplantion 83:282–289
Kamar N, Oufroukhi L, Faure P, Ribes D, Cointault O, Lavayssiere L, Nogier MB, Esposito L, Durand D, Rostaing L (2005) Questionnaire-based evaluation of gastrointestinal disorders in de novo renal-transplant patients receiving either mycophenolate mofetil or enteric-coated mycophenolate sodium. Nephrol Dial Transplant 20:2231–2236
Altiparmak MR, Trablus S, Pamuk ÖN, Apaydin S, Sariyar M, Oztürk R, Ataman R, Serdengeçti K, Erek E (2002) Diarrhea following renal transplantation. Clin Transplant 16:212–216
Fishman JA, Rubin RH (1998) Infection in organ-transplant recipients. N Engl J Med 338:1741–1751
Helderman JH (2001) Prophylaxis and treatment of gastrointestinal complications following transplantation. Clin Transplant 15:29–35
Forrest G (2004) Gastrointestinal infections in immunocompromised hosts. Curr Opin Gastroenterol 20:16–21
Guerrant RL (1997) Cryptosporidiosis: An emerging, highly infectious threat. Emerg Infect Dis 3:51–57
Meinhardt PL, Casemore DP, Miller KB (1996) Epidemiologic aspects of human cryptosporidiosis and the role of waterborne transmission. Epidemiol Rev 18:118–136
Chieffi PP, Sens YA, Paschoalotti MA, Miorin LA, Silva HG, Jabur P (1998) Infection by Cryptosporidium parvum in renal patients submitted to renal transplant or hemodialysis. Rev Soc Bras Med Trop 31:333–337
Roncoroni AJ, Gomez MA, Mera J, Cagnoni P, Michel MD (1989) Cryptosporidium infection in renal transplant patients. J Infect Dis 160:559
Clifford CP, Crook DW, Conlon CP, Fraise AP, Day DG, Peto TE (1990) Impact of waterborne outbreak of cryptosporidiosis on AIDS and renal transplant patients. Lancet 335:1455–1456
Minz M, Udgiri NK, Heer MK, Kashyap R, Malla N (2004) Cryptosporidiasis in live related renal transplant recipients: a single center experience. Transplantation 77:1916–1917
Franco A, Rocamora N, Merino E, Paya A (2006) Cryptosporidiosis. A rare infection in renal transplantation. Nefrologia 6:753–754
Tran MQ, Gohh RY, Morrissey PE, Dworkin LD, Gautam A, Monaco AP, Yango AF Jr (2005) Cryptosporidium infection in renal transplant patients. Clin Nephrol 63:305–309
Abdo A, Klassen J, Urbanski S, Raber E, Swain MG (2003) Reversible sclerosing cholangitis secondary to cryptosporidiosis in a renal transplant patient. J Hepatol 38:688–691
Campos M, Jouzdani E, Sempoux C, Buts JP, Reding R, Otte JB, Sokal EM (2000) Sclerosing cholangitis associated to cryptosporidiosis in liver-transplanted children. Eur J Pediatr 159:113–115
Urban JF Jr, Fayer R, Chen SJ, Gause WC, Gately MK, Finkelman FD (1996) IL-12 protects immunocompetent and immunodeficient neonatal mice against infection with Cryptosporidium parvum. J Immunol 156:263–268
Theodos CM (1998) Innate and cell-mediated immune responses to Cryptosporidium parvum. Adv Parasitol 40:87–119
Abubakar I, Aliyu SH, Arumugam C, Usman NK, Hunter PR (2007) Treatment of cryptosporidiosis in immunocompromised individuals: systematic review and meta-analysis. Br J Clin Pharmacol 63:387–393
Sellin JH (2001) The pathophysiology of diarrhea. Clin Transplant 15:2–10
Striepen B, Pruijssers AJ, Huang J, Li C, Gubbels MJ, Umejiego NN, Hedstrom L, Kissinger JC (2004) Gene transfer in the evolution of parasite nucleotide biosynthesis. Proc Natl Acad Sci USA 101:3154–3159
Ochoa TJ, White AC Jr (2005) Nitazoxanide for treatment of intestinal parasites in children. Pediatr Infect Dis J 24:641–642
Amadi B, Mwiya M, Musuku J, Watuka A, Sianongo S, Ayoub A, Kelly P (2002) Effect of nitazoxanide on morbidity and mortality in Zambian children with cryptosporidiosis: A randomized controlled trial. Lancet 360:1375–1380
Acknowledgments
We thank Karine Guyot (Institut Pasteur, Lille, France) and the Cryptosoridium ANOFEL network for genotyping the isolates and Joost P. Schanstra (Inserm U858, Toulouse, France) for proofreading the manuscript and for helpful comments.
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Bandin, F., Kwon, T., Linas, MD. et al. Cryptosporidiosis in paediatric renal transplantation. Pediatr Nephrol 24, 2245–2255 (2009). https://doi.org/10.1007/s00467-009-1274-y
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DOI: https://doi.org/10.1007/s00467-009-1274-y