New-onset inflammatory bowel disease in patients after kidney transplantation

Article by Doctor Mai Vien Phuong - Department of Medical Examination & Internal Medicine - Vinmec Central Park International General Hospital

New-onset inflammatory bowel disease after transplantation usually presents late in follow-up, with a median delay of up to 91 months. The clinical presentation of new-onset inflammatory bowel disease resembles those occurring in the general population, including bloody diarrhea and abdominal pain.

Although inflammatory bowel disease is characterized by autoimmune pathogenesis and the renal transplant patient is immunosuppressed. However, the current incidence of IBD following solid organ transplantation is up to 550 cases/100000 individuals, approximately 10 times higher than rates observed in the general population (about 7-10 cases/100000 individuals). individual).
New-onset inflammatory bowel disease after kidney transplantation is uncommon, with only 46 cases reported in the literature. An additional 7 cases were reported by a French multicenter study. Furthermore, most new-onset inflammatory bowel disease occurs in liver transplant recipients. Only about 5% of solid organ transplant-associated inflammatory bowel disease occurs in kidney recipients. Interestingly, a recent multicenter study of post-renal inflammatory bowel disease found no correlation between pre-existing autoimmune disease or immunosuppressive therapy and inflammatory bowel disease before or after renal transplantation.

New-onset inflammatory bowel disease after transplantation usually presents late in follow-up, with a median delay of up to 91 months. The clinical presentation of new-onset inflammatory bowel disease resembles those occurring in the general population, including bloody diarrhea and abdominal pain. The histological features of post-renal transplantation enteritis are enlargement of the stroma by a dense lymphoplasmacytic infiltrate with basal plasmacytosis, crypt architecture distortion, and vesicle inflammation.

The course of inflammatory bowel disease after renal transplantation appears to be much stronger than that of inflammatory bowel disease in the general population. The disease is associated with increased mortality and difficult treatment management, especially because of the possible interaction between immunosuppressive drugs and specific therapy for inflammatory bowel disease.
Corticosteroids can provide clinical remission of inflammatory bowel disease, but they cannot maintain it as monotherapy. This may be due to their failure to induce adult T-lymphocyte death, allowing acute and chronic inflammatory bowel disease exacerbations.

Inflammatory bowel disease may present as a pre-existing exacerbation or, rarely, new-onset inflammatory bowel disease occurring in patients without any prior symptoms. New-onset diseases after transplantation may have a more aggressive clinical course.
The combination of clinical, endoscopic and histological features is useful to distinguish between the causes of gastrointestinal symptoms affecting kidney transplant recipients. The clinical manifestations of IBD after renal transplantation are diverse and patients are usually diagnosed after excluding other causes. In most cases, patients present with symptoms such as bloody diarrhea and abdominal cramps.

Studies on MMF (immunosuppressive drug Mycophenolate mofetil) have had mixed results, because in some studies, MMF was unable to maintain remission in patients with inflammatory bowel disease, whereas others Other research shows that its use leads to improvement in symptoms.
Tacrolimus and cyclosporine, although highly effective in preventing rejection after renal transplantation, have been shown to be ineffective in the treatment of new-onset inflammatory bowel disease. Although recent observations in a non-transplant population suggest that tacrolimus may have short-term clinical benefit in the management of inflammatory bowel disease. Contradictory results have been obtained even with the use of azathioprine in maintenance therapy.
Timmer et al demonstrated that azathioprine was less effective than sulfasalazine or mesalazine due to possible side effects such as bone marrow suppression and increased susceptibility to infection in immunocompromised renal recipients. Translate. Azathioprine should only be used as maintenance therapy in the event of failure of a mesalazine-based regimen or in cases where the patient requires repeated steroids.
Of all reported cases of new-onset inflammatory bowel disease, 16 occurred in kidney transplant recipients. These people have been successfully treated with conventional inflammatory bowel disease therapy (mesalazine, corticosteroids, and azathioprine). About half of patients are resistant to conventional inflammatory bowel disease therapy combined with immunosuppression.
Currently, Vinmec International General Hospital has introduced Tacrolimus into the care and treatment system, to ensure that patients can use the appropriate tacrolimus dose regimen to optimize treatment effectiveness, minimize the risk of kidney transplant rejection as well as limiting the unwanted effects of the drug. Therefore, the hospital will help patients after kidney transplant improve their quality of life and maintain the daily routine that the patient used to have.

References
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(38): 5797-5811 [PMID: 33132635 DOI: 10.3748/wjg.v26.i38.5797]