Duodenal Villous Atrophy: A Cause of Chronic Diarrhea After Solid-Organ Transplantation

Abstract

† These two authors equally participated to this work.Persistent diarrhea is commonly observed after solid organ transplantation (SOT). A few cases of mycophenolate mofetil (MMF)-induced duodenal villous atrophy (DVA) have been previously reported in kidneytransplant patients with chronic diarrhea. Herein, we report on the incidence and characteristics of DVA in SOT patients with chronic diarrhea. One hundred thirty-two SOT patients with chronic diarrhea underwent an oesophago-gastroduodenoscopy (OGD) and a duodenal biopsy after classical causes of diarrhea have been ruled out. DVA was diagnosed in 21 patients (15.9%). It was attributed to mycophenolic acid (MPA) therapy in 18 patients (85.7%) (MMF [n = 14] and enteric-coated mycophenolate sodium [n = 4]). MPA withdrawal or dose reduction resulted in diarrhea cessation. The incidence of DVA was significantly higher in patients with chronic diarrhea receiving MPA compared to those who did not (24.6% vs. 5.1%, p = 0.003). DVA was attributed to a Giardia lamblia parasitic infection in two patients (9.5%) and the remaining case was attributed to azathioprine. In these three patients, diarrhea ceased after metronidazole therapy or azathioprine dose reduction. In conclusion, DVA is a frequent cause of chronic diarrhea in SOT recipients. MPA therapy is the most frequent cause of DVA. An OGD should be proposed to all transplant recipients who present with persistent diarrhea.

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“…A recent study on DVA in SOT patients concluded that a main cause of DVA (24.6%) can be secondary to mycophenolate mofetil therapy. 2 In our study, mycophenolate mofetil was administered to 54 patients (51.9%), azathioprine to 50 patients (48.1%), tacrolimus to 40 patients (38%), and cyclosporine to 38 patients (36.5%) who developed DVA after transplant. The difference in immunosuppressive regimens can be due to the versatility of organs transplanted.…”

“…[1][2][3][4] Posttransplant diarrhea not only leads to weight loss, dehydration, deranged serum creatinine, and inconsistent immunosuppressive drug levels, it also enhances the risk of graft loss and patient death. 1,[5][6][7][8] In our analyses of baseline characteristics, sex distribution in our study group was different from a previous study in which female sex and diabetes emerged as independent risk factors for diarrhea.…”

“…Farina M. Hanif, 1 Nasir Hassan Luck, 1 Zaigham Abbas, 1 Tahir Aziz,2 Syed Mujahid Hassan, 1 Muhammed Mubarak exclusively. Therefore, in this study, our aim was to investigate the frequency of DVA and its possible causes in renal transplant patients so that patients could be screened for early diagnosis and appropriate treatment to improve both patient and graft survival.…”

“…1,2 Infectious diarrhea and drugrelated diarrhea account for up to 60% of such cases. 3 Persistent diarrhea alters a patient's quality of life, causes fatigue and weight loss, increases the number of hospital admissions, increases serum creatinine levels, and causes alterations in immunosuppressive therapy dose levels.…”

“…4 Diarrhea is also associated with an increased risk of graft failure and patient death after kidney transplant. 2 Recently, Weclawiak and associates 2 reported the prevalence of duodenal villous atrophy (DVA) to be 15.9% in SOT patients as a cause of persistent diarrhea. Studies in immunocompromised patients have shown celiac disease and tropical sprue as important causes of DVA, whereas, in SOT recipients, giardiasis (5.3% to 14%) and medications, most commonly mycophenolate mofetil (13% to 31%) and azathioprine (21%), have been implicated as frequent causes.…”