Year : 2008 | Volume
: 19 | Issue : 4 | Page : 624--626
Denovo Post Renal Transplantation Inflammatory Bowel Disease
MA Halim, T Al-Otaibi, A Elsisi, A El-Sayed, P Nair, T Said, MA Balaha, MRN Nampoory
Hamed Al Essa Organ Transplantation Centre, Kuwait
M A Halim
Hamed Al Essa Organ Transplantation Centre, Ibn Sina Hospital, P.O. Box 25427, Code 13115, Safat
Post-renal transplant de-novo inflammatory bowel disease (IBD) may develop despite the presence of mycophenolate mofetil (MMF), a drug used for treatment of IBD, in the immunosuppressive regimen. A 39-year-old man received live unrelated renal transplant, and was started postoperatively on prednisolone, MMF, and tacrolimus, which was changed to sirolimus when he developed diabetes mellitus two months post-transplant. Nine months post-transplant, the patient developed recurrent attacks of bloody diarrhea and ischio-rectal abscesses complicated by anal fistulae not responding to routine surgical treatment. Colonoscopy diagnosed IBD, a Crohn«SQ»s disease-like pattern. The patient was treated with steroids and 5-aminosalicylic acid (5ASA) in addition to a two months course of ciprofloxacin and metronidazole. He became asymptomatic and rectal lesions healed within one month of treatment. The patient continued to be asymptomatic, and he maintained normal graft function on the same immunosuppressive treatment in addition to 5-ASA. We conclude that de-novo IBD disease can develop in renal transplant recipients in spite of immunosuppressive therapy including MMF.
|How to cite this article:|
Halim M A, Al-Otaibi T, Elsisi A, El-Sayed A, Nair P, Said T, Balaha M A, Nampoory M. Denovo Post Renal Transplantation Inflammatory Bowel Disease.Saudi J Kidney Dis Transpl 2008;19:624-626
|How to cite this URL:|
Halim M A, Al-Otaibi T, Elsisi A, El-Sayed A, Nair P, Said T, Balaha M A, Nampoory M. Denovo Post Renal Transplantation Inflammatory Bowel Disease. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2020 Jul 4 ];19:624-626
Available from: http://www.sjkdt.org/text.asp?2008/19/4/624/41325
Post transplant de-novo inflammatory bowel disease (IBD) is rare, and it is affected by the immune tolerance and modality of immunosuppression.  Mycophenolate mofetil (MMF) may be associated with post transplant IBD. , On the other hand, MMF is also reported to be a reasonable alternative in treating and maintain remission of Crohn's disease (CD) for patients who do not tolerate azathioprine (AZA). 
We report a case of IBD in post renal transplant recipient who developed IBD in the presence of MMF in the immunosuppressive therapy, however, he recovered despite continuing the same immunosuppressive regimen.
A 39-year-old man who developed chronic renal failure due to advanced nephrosclerosis, and underwent hemodialysis treatment for 9 months before he received a live unrelated renal transplant. Postoperatively, immunosuppression was induced with anti-thymocyte globulin (ATG) in addition to steroid, MMF, and tacrolimus, and the latter three drugs were continued as maintenance therapy. Tacrolimus was changed to sirolimus when the patient developed diabetes mellitus 2 months post-transplantation.
Nine months post-transplant, the patient developed recurrent attacks of nausea, abdominal pain and diarrhea, occasionally bloody, and associated with ischiorectal abscesses complicated by anal fistulas, which were not responding to routine surgical management including incision and drainage, in addition to antibiotics.
At the time of the new complaint, the patient was maintained on prednisolone 10 mg/day, MMF 500mg twice/day, and sirolimus 4mg/d; sirolimus trough level was 7.6 ng/dl. He was treated with oral antibiotics empirically for possible infective diarrhea with temporary and inadequate response. Upper gastro-intestinal (GI) endoscopy revealed hiatus hernia, while colonoscopy disclosed multiple erythematous colonic lesions with aphthous ulcers and erosions.
Colonic biopsies demonstrated mild chronic lymphoplasmacytic cell infiltration of the lamina propria with cryptitis and noncaseating granulomatous lesions. There was no evidence of acid fast bacilli or viral infection in the biopsies.
Claustridium defficille toxin, cytomegalovirus (CMV) antigen, and P-anti-neutrophil cytoplasmic antibody were negative. Other laboratory investigations were not conclusive except for mild anemia and high C-reactive protein.
The patient was diagnosed to have IBD, Crohn's disease-like pattern. He was treated with steroids and 5-aminosalicylic acid (5ASA) in addition to a 2-month course of ciprofloxacin and metronidazole, and he was continued on the same doses of MMF and sirolimus. Within one month of treatment, the patient became asymptomatic, and his rectal lesions healed completely. During follow-up, he remained asymptomatic and maintained normal graft function on the same immunosuppressive treatment and 5-ASA.
MMF is widely used for maintenance immunosuppression in solid organ transplantation replacing AZA.  Gastrointestinal toxicity, usually manifests as diarrhea, is the most common side effect of MMF.  A full spectrum of new onset IBD can develop after solid organ transplantation, despite the use of immunosuppressive therapy.  Reduction or cessation of MMF was the only effective therapy to control IBD in such patients but with increased risk of rejection. 
The prevalence of IBD after transplantation is affected by the type of immunosuppression used. Azathioprine was presented as a protector and tacrolimus as a promoter of IBD.  MMF can maintain remission and replace AZA if not tolerated as a treatment for IBD. , Our patient developed an immunological disease in spite of adequate immunosuppression. Although a significant degree of allograft tolerance can occur, autoimmune diseases can still develop elsewhere, suggesting selective immune tolerance.  IBD was successfully controlled in our patient without reduction of MMF dose for 6 months. 
We conclude that de-novo IBD can develop post renal transplantation in spite of adequate immunosuppressive therapy even when MMF is used. However, IBD can be controlled without discontinuing MMF. Long term follow-up is required to assess the disease activity while on MMF.
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