Celiac-like Enteropathy Associated With Mycophenolate Sodium in Renal Transplant Recipients

Abstract

BackgroundAlthough colonic injury is a well-known complication of mycophenolic acid (MPA), the involvement of the upper gastrointestinal tract is less extensively documented. We present the occurrence of celiac-like duodenopathy manifested as a severe diarrhea syndrome in 2 renal transplant recipients on enteric-coated mycophenolate sodium.MethodsThe patients belong to a setting of 16 renal transplant recipients under MPA suffering from chronic diarrhea in the absence of MPA-related colitis.ResultsBoth patients had a history of persistent diarrhea with significant weight loss. Colonic mucosa was unremarkable, whereas duodenal biopsies revealed celiac-like changes with increased epithelial cell apoptosis. Clinical symptoms completely resolved, and follow-up biopsies demonstrated normalization of histology after enteric-coated mycophenolate sodium withdrawal and switching to azathioprine.ConclusionsCeliac-like enteropathy seems to represent a rare side effect of MPA-associated immunosuppressive therapy and should be taken into account in the differential diagnosis of diarrhea in transplant recipients treated with MPA particularly in the absence of MPA-related colitis. As macroscopic lesions are usually missing, blind duodenal biopsies are necessary to establish the diagnosis.

The Utilization and Diagnostic Yield of Upper Endoscopy for Evaluation of Gastrointestinal Symptoms Within the First Year After Liver Transplantation

“…In the patient with villous atrophy, testing for celiac disease was negative; therefore, the finding was attributed to the use of immunosuppressive medication (mycophenolate), as celiac-like enteropathy has been reported in several cases with the use of mycophenolate sodium [23].…”

Gastrointestinal injury induced by immunomodulators: A review article

“…The major histology pattern from duodenal biopsies showed a combination of villous atrophy and intraepithelial lymphocytosis, and lack of epithelial cell apoptosis and prominent lymphoplasmacytic mucosa infiltrates, which differed from genuine celiac disease. 13 …”

“…12 MMF-associated colitis is histologically characterized by crypt distortion, prominent crypt cell apoptosis, edematous lamina propria, and inflammatory cells infiltration, which are similar to IBD (Supplemental Table 1) and GVHD. 13,14 Even some case reports provided evidence of celiac-like duodenopathy as a rare complication of MMF in kidney transplant recipients. These patients who were negative in serology and HLA genotyping for celiac disease presented with severe chronic diarrhea and substantial weight loss.…”

“…The major histology pattern from duodenal biopsies showed a combination of villous atrophy and intraepithelial lymphocytosis, and lack of epithelial cell apoptosis and prominent lymphoplasmacytic mucosa infiltrates, which differed from genuine celiac disease. 13 Most GI AEs caused by MMF are self-limiting. A prospective study showed that switching to enteric-coated MMF had a significant improvement in GI-related toxicities in liver transplant recipients.…”