Acute Diarrhea in Early Post-Transplant Period in Living Donor Kidney Transplant Recipients
Authors:   Professor and Head/Senior Consultant Physician, Department of Medicine/ Department of Nephrology, Defence Services Medical Academy, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Myanmar, Pyar Khin Phyu , Shwe Win Kyaw ,   Senior Consultant Nephrologist, No. (2) Defence Services General Hospital (1000-Bedded), Nay Pyi Taw, Myint Moe Zaw ,   Senior Consultant Physician, No. (2) Defence Services General Hospital (1000-Bedded), Nay Pyi Taw, Win Kyaw Soe ,   Senior Consultant Physician, No. (2) Defence Services General Hospital (1000-Bedded), Nay Pyi Taw, Saw Aung Myo ,   Senior Consultant Physician, No. (2) Defence Services General Hospital (1000-Bedded), Nay Pyi Taw, Aung Zaw Lin ,   Senior Consultant Physician, No. (2) Defence Services General Hospital (1000-Bedded), Nay Pyi Taw, Htet Aung Zaw ,   Senior Consultant Nephrologist, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Wynn Thurein ,   Consultant Physician, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Kyaw Aung Phyoe ,   Consultant Physician, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Oo Kaung Myat ,   Consultant Pathologist, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Htike Zaw Min ,   Consultant Microbiologist, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Sint Aung Khin ,   Consultant Pharmacologist, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Maung Kyaw Thet ,   Consultant Physician, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Thu Aung ,   Consultant Physician, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Thu Ye Min ,   Consultant Physician, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Ya Kyaw Zay ,   Consultant Physician, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Kyaw Myo Thant ,   Consultant Physician, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Aung Zay Phyo ,   Consultant Physician, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Aung Han Lin ,   Consultant Physician, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Latt Aung Phyo ,   Consultant Physician, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Aung Zin Zin ,   Consultant Nephrologist, No. (2) Defence Services General Hospital (1000-Bedded), Nay Pyi Taw, Maung Myo Maung ,   Consultant Nephrologist, No. (2) Defence Services General Hospital (1000-Bedded), Nay Pyi Taw, Hein Min Aung ,   Consultant Nephrologist, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Lwin Kyaw Thurein ,   Consultant Nephrologist, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Aung Wai Lynn ,   Consultant Physician, No. (1) Defence Services General Hospital (1000-Bedded), Yangon, Min Sitt ,   Consultant Physician, No. (1) Defence Services General Hospital (1000-Bedded), Yangon
Published: January 2024

Background: Acute diarrhea is common in Myanmar. People are so used to diarrhea at least once a year that they do not think diarrhea as an important problem. Acute diarrhea in early post-operative period in renal transplant recipient may result in pre-renal failure and delay graft function. This study aimed to identify the prevalence of diarrhea, its severity and response to treatment in early post-operative period (3 weeks after transplant) in living donor kidney transplant (LDKT) recipients. Patients and Methods: LDKT recipients having acute diarrhea in early post-transplant period at two transplant centers (Mingaladon and Nay Pyi Taw) in Myanmar were analyzed over 10 years period; from 2013 to 2023 September. Acute diarrhea is defined as three or more semisolid or liquid stools per day for a minimum of 1 day duration. It was a hospital based observational study. After obtaining diet history and physical examination, laboratory tests were done. Clinical parameters (diet, fever, features of oral candidiasis, features of dehydration, examination of abdomen), stool examination (stool inspection, stool examination for ova and cyst, stool for Clostridium difficle toxin, stool culture), blood tests (total WBC count, serum creatinine, liver function tests) and blood trough level for Tacrolimus and mycophenolate mofetil were done. Management was given according to algorithm and their response to treatment was recorded. Dose modification of immunosuppressants were done depending on full blood count and blood level of them. Results: A total of 230 LDKT recipients were observed; among them, thirteen percent (30/230) of recipients developed acute diarrhea in early post-operative period. The age ranged from 14 to 73 years. A majority of them had mild form; mild dehydration without significant changes in hemodynamic status. The peak onset of diarrhea was 4 to 5 days after transplant; majority resolved over one week. They did not have oral candidiasis. Abdominal examination was normal except mild tenderness over grafted kidney in all of them. Total WBC count and platelet count were normal except in two cases. Stool examination did not show trophozoite or cyst. Stool for Clostridium difficile toxin was not identified. With dietary modification and oral rehydration solution, their motion was back to normal in sixteen percent (5/30). Folic acid therapy with or without probiotics made resolution of diarrhea in 33.3% (10/30). Anti-infective therapy was given in 10% (3/30) of cases; norfloxacin to 2 cases. Intravenous colistin to one case as he had enterocolitis and septicemia due to Klebsiella pneumonia. His stool culture as well as blood culture showed Carbepenem resistant Klebsiella pneumonia; he was known case of myelodysplastic syndrome. Blood level of mycophenolate mofetil was normal; however, the dose was reduced in 2 cases owing to leucopenia or thrombocytopenia. Blood tacrolimus trough level was normal in two-third (20/30); and, it was high in one-third of them (20/30). They passed formed stool 24 - 48 hours after dose reduction of tacrolimus. Conclusion: In this study, 13% of the LDKT recipients had acute diarrhea in early post-operative period. Majority of them had mild form. Half of them recovered with oral rehydration solution, diet modification, folic acid and probiotics. Only one tenth of them had infective in origin and responded to anti-infective therapy. Raised blood tacrolimus trough level was found in one third of LDKT recipients with acute diarrhea; diarrhea improved dramatically after reduction of tacrolimus dose.