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RESEARCH ARTICLE
Year : 2004  |  Volume : 20  |  Issue : 2  |  Page : 33-35
 

Gastrointestinal complications in renal transplantation


SGPGIMS, Lucknow, India

Correspondence Address:
Aneesh Srivastava
Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Objective: Gastrointestinal complications are responsible for substantial morbidity and mortality among renal allograft recipients. We retrospectively analyzed incidence of these complications and their impact on the patient outcome.
Materials & Methods: Between 1998 to Aug 2002, 558 live related renal transplants were performed at our center. The immunosuppression used consisted mainly of cyclosporine, azathioprine and prednisolone, though varied in some patients. These patients were followed for any occurrence of significant gastrointestinal problems.
Results: Out of the of 538 renal transplant recipients studied, gastro esophageal ulcerations were seen in 3% patients. Acute pancreatitis was observed in twelve (2.2%) patients and four patients had acute intestinal obstruction secondary to fecal impaction. Infectious complications included acute diarrheas in 18% of patients. Three patients developed abdominal tuberculosis. Acute rejection episodes were encountered in 26% of the patients. During these episodes, 58% of patients experienced prolonged ileus. Most of these complications (66%) occurred within first one-year post transplant. Three patients presenting with acute intestinal obstruction required laparotomy (two- bands, one­intussusception). There were four mortalities -two patients had severe pancreatitis, one patient had massive upper GI bleed and one succumbed due to perforation peritonitis.
Conclusions: Gastrointestinal complications account for significant morbidity and mortality in renal transplant recipients. Paralytic ileus secondary to acute vascular rejection is quite common and resolves spontaneously with recovery of renal function.


Keywords: GI complications, Renal transplant,


How to cite this article:
Singh KJ, Srivastava A, Suri A, Srivastava A, Dubey D, Kapoor R, Kumar A. Gastrointestinal complications in renal transplantation. Indian J Urol 2004;20:33-5

How to cite this URL:
Singh KJ, Srivastava A, Suri A, Srivastava A, Dubey D, Kapoor R, Kumar A. Gastrointestinal complications in renal transplantation. Indian J Urol [serial online] 2004 [cited 2019 Oct 22];20:33-5. Available from: http://www.indianjurol.com/text.asp?2004/20/2/33/37165



   Introduction Top


Gastrointestinal(GI) complications though infrequent in renal transplant recipients are associated with significant morbidity and mortality. Etiology of these complications are not clear. These lesions can occur at any level of GI tract. These complications may be life threatening and may lead to graft loss and even death of the patients. Advent of newer immuno-suppression and advances in the surgical field have led to decrease in the morbidity and mortality. A search of relevant literature in this regard revealed only a limited number of studies addressing this issue [1],[2],[3]. This study attempts to assess the incidence of gastrointestinal complications and their impact on the outcome of the recipients.


   Material and Methods Top


The study involved 558 live related renal transplants which were performed at our center between 1998 and Aug 2002. Age of the patients ranged from 6-56 years with male to female ratio of 1.7:1. The immunosuppression used consisted primarily of cyclosporine, azathioprine and prednisolone, though itvaried in some patients

These patients were followed for any occurrence of complications related to the gastrointestinal system. Complications were divided into two groups a) upper mesocolic (gastric ulcer, duodenal ulcer, upper GI bleeding, acute gastroduodenal ulceration, esophagitis, and acute pancreatitis) and b) lower mesocolic (small and large bowel pathologies) as suggested by Benoit et al in their study [1] .


   Results Top


One hundred and twenty seven patients had one or more GI complications [Table 1].

One hundred and eleven patients had minor complications (ulceration, ileus and diarrhea), while twenty six had major complications( perforation, hepatitis, pancreatitis, intestinal obstruction, colon malignancy and abdominal tuberculosis).

Upper mesocolic complications: Seventeen patients had gastrointestinal ulceration as diagnosed on endoscopy, where as eight patients had pancreatitis [Table 2]. Most common site of ulceration was the first part of duodenum seen in 10 patients.

Gastric ulceration was encountered in four and esophageal ulceration in three patients. All the patients were treated with proton pump inhibitors and non absorbable antacids. Ulceration was more common within first year of transplant than in the second year (11 vs 6). Ten out of eleven (91%) developing ulceration had previously diagnosed ulceration on endoscopy, while only one patient out of six (17%) developing ulceration in second year had prior history of upper GI ulceration. Three patients required surgical intervention. -Two patients had perforation while one patient had significant bleed. All these complications were secondary to duodenal ulceration. Out of these two patients died, one with perforation and the other with bleed. Eight patients had acute pancreatitis which was managed conservatively and was more common during first year as compared to the second year. Two patients of acute pancreatitis died within first year of transplant, secondary to acute necrotizing pancreatitis.

Lower mesocolic complications: Seven patients had intestinal obstruction and this was more common within first year as compared to subsequent year (5 vs 2). The etiology of the obstruction has been summarized in [Table 3]

Surgical intervention was required in all the patients with band and intussusception while the patient with sub acute intestinal obstruction were managed conservatively. One hundred and forty five patients had acute rejection: eighty four patients had acute vascular rejection and 61 patients had acute cellular rejection. Duration of ileus was significantly more in patient who developed rejection episodes in comparison to patients who did not have rejection episodes (mean 5.5 vs 1.3 days, p<0.05). A higher incidence of ileus (n=40) was observed in patients who had rejection episodes. Patients with vascular rejection (n=29) had a higher incidence of ileus as compared to patients with cellular rejection (n= 11). Mean duration of ileus was 6.7±2.3 days. All patients responded to conservative management.

Two patients had colonic malignancy for which they underwent colectomy and end to end anastomosis for stage II disease. Both received allograft more than 2 years ago. Three patients had abdominal tuberculosis. Two out of these patients had tubercular ascites and one had subacute intestinal obstruction. All patients received anti-tubercular treatementfor 9 months and they all responded.

When compared gastrointestinal complications were overall more common in first year as compared to subsequent years [Table 4].


   Discussion Top


Gatrointestinal complications lead to significant morbidity and mortality after renal transplantation though major complications occur infrequently. In our study, the gastrointestinal complications were seen in 22.8% of the recipients while Benoit et al reported an incidence of 16.8 in their study [1] .

We experienced gastro-duodenal ulceration in 13.38 patients (n=17) in spite of these patients being on H2 blockers. This is slightly higher than 9.6% as reported by Troppman et a14. We experienced perforation rate of 11% of all the patients who had ulceration with morality rate of 5% which is similar to that reported by Garvin et al [5] but is slightly higher than that reported by Troppmann et al [2] who reported an incidence of 3% in their study. Advent of newer proton pump inhibitors along with availability of newer immuno suppressive regimens with lower doses of steroids have greatly decreased the mortality due to perforation than was reported in the earlier literature [4] . Only one patient in our study had upper gastrointestinal bleed secondary to the duodenal ulceration and was managed surgically, while Troppmann et al had observed upper gastrointestinal bleeding in 15 patients out of 33 patients with peptic ulceration in their study [4].

As for pancreatitis, our incidence rate of 1.4% is comparable to that reported in literature [2],[7],[8]. We experienced a mortality rate of 25% in patients of acute pancreatitis as compared to 12.5% observed by Benoit [1] .

Most of gastrointestinal complications (60%) occurred during the first year of transplantation, while subsequently the complications were relatively less common (40%). The patients with acute rejection episodes (26%) had a high incidence of paralytic ileus. During rejection episodes 58% of these patients developed prolonged ileus requiring temporary cessation of oral feeds and prescribing intravenous fluids. These were seen more commonly in patients experiencing vascular rejection as compared to those having cellular rejection (73.6 vs. 26.4%). We did not come across any study on MEDLINE which could explain the effect of rejection on the the bowel peristaltic activity. However, we feel that intense perigraft reaction and severe edema associated with the acute vascular rejection could lead to a meteroism like situation and should logistically explain the higher the incidence of paralytic ileus as opposed to acute cellular rejections which usually cites minimal perigraft reaction.

Gastrointestinal infections were common in these patients. Acute diarrhea was seen in 17.3% (n=22) of these patients developing gastrointestinal complications and this is similar to that reported by Kathuria et al in their study [8] . Tuberculosis is a common disease in India and the incidence has increased due to immuno therapy. 2.3 % of our patients had abdominal tuberculosis(n=3) as compared to affection of 6% patients in another study from this country [3] .

There were four mortalities (3.14%) observed in our study: Two patients had acute severe pancreatitis, one had perforation peritonitis and one died because of acute gastrointestinal bleed. Our mortality rate in patient undergoing surgical intervention for the gastrointestinal complications (perforation, bleeding or intestinal obstruction) is similar to that reported in literature [1] .


   Conclusion Top


Adequate prophylaxis with anti ulcer drugs, good hygiene early diagnosis, and appropriate treatment are needed to decrease the frequency and severity of gastrointestinal complications in renal allograft recipients. Gastrointestinal complications account for significant morbidity and mortality in renal transplant recipients. Paralytic ileus secondary to acute vascular rejection is quite common and resolve spontaneously.

 
   References Top

1.Benoit G, Moukarzel M, Verdelli G, Hiesse C, Buffet C, Bensadoum H, charpentier B, Jardin A, Fries D. Gastrointestinal complications in renal transplantation. Transpl Int 1993;6:45-9.  Back to cited text no. 1    
2.Qwens ML, Wilson Se, Saltzman R, Gordon E. Gastrointestinal complication after renal transplant. Arch Surg 1976;11: 467-71.  Back to cited text no. 2    
3.Kathuria P, Sakhuja V, Gupta KL, Jha V, Kochar R, Joshi K, Kalra OP, Chugh KS. Gastrointestinal complications after renal transplantation. 10 year data from a North Indian Transplant Centre. ASAIO J. 1995;41: M698­-703.  Back to cited text no. 3    
4.Troppmann C, Papalois BE, Chiou A, Benedetti E, Dunn L, Matas AJ, Najarian JS, Gruessner GW. Incidence, complications, treatment and outcome of ulcers of the upper gastrointestinal tract after renal transplantation during cyclosporine era. J Am Coll Surg 1995; 180 :433-43.  Back to cited text no. 4    
5.Garvin PJ, Carvey K, Casteneda M. Peptic ulcer disease following renal transplantation: role of cimetidine. Am J Surg 1982;144:545.  Back to cited text no. 5    
6.Stuart FP, Reckard CR, Schulak JA, Ketel BL. Gastroduodenal complications in kidney transplant recipients. Ann Surg 1981; 194: 339-44.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Alexander JA, Demetius AJ, Gavalla JS, Makowa L, Starzl TE, Thiel DH van. Pancreatitis following liver transplantation. Transplantation 1988; 45: 1062-5.  Back to cited text no. 7    
8.Fernandez Cruz L, Targorona EM, Lugat E, Alcaraz A, Oppenheimer F. Acute pancreatitis after renal transplantation. BrJ Surg 1989; 76: 1132-5.  Back to cited text no. 8    




 

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    Abstract
    Introduction
    Material and Methods
    Results
    Discussion
    Conclusion
    References

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