Diarrhea in the pediatric solid organ transplantation recipient: A multidisciplinary approach to diagnosis and management

Abstract

Diarrhea in the pediatric solid organ transplantation (SOT) recipient is a frequent complaint that is associated with significant morbidity and impaired quality of life. There are limited published data regarding the specific epidemiology, diagnostic evaluation, and treatment of diarrhea after SOT in children. Pediatric SOT recipients have an increased risk of developing diarrhea because of a generalized immunosuppressed state, epidemiologic exposures, and polypharmacy. There is a need to standardize the diagnostic evaluation of diarrhea in children after SOT to facilitate an accurate diagnosis and timely treatment. Herein, we review the available published data and propose a systematic, stepwise approach to the evaluation of diarrhea in this high‐risk population, focusing on timely diagnosis of both infectious and non‐infectious causes, in order to provide focused management. Prospective studies are needed to better assess the true prevalence, risk factors for, etiologies, and complications of diarrhea in pediatric SOT patients that will guide optimal management. Development of effective vaccines and antiviral therapies for enteric viruses may also contribute to improved outcomes.

Association of intraindividual tacrolimus variability with de novo donor-specific HLA antibody development and allograft rejection in pediatric kidney transplant recipients with low immunological risk

“…In our patient cohort, the dn DSA-positive subgroup had a longer cold ischemia time than the dn DSA-negative subgroup and less frequently received steroids at year 1 posttransplant than the dn DSA-negative subgroup. However, in a large prospective randomized trial on steroid avoidance in pediatric kidney transplantation, steroid-free immunosuppression was not associated with a higher frequency of dn DSA development [ 41 ].…”

Gastrointestinal symptoms and endoscopy findings after pediatric solid organ transplantation: A case series

“…The risk for malignancies is known to be increased after SOT and especially PTLD is recognized to be one of the most devastating complications after transplantation. 7,13 PTLD can manifest in any organ, but the gastrointestinal tract is commonly involved and GI PTLD is associated with a high mortality. 7,14 Up to half of our patients who underwent endoscopy for intestinal symptoms had PTLD.…”

“…The causes of diarrhea are various; however, among SOT recipients, one potential risk factor is increased susceptibility to different infections. Clostridium difficile , norovirus, and cytomegalovirus (CMV) are the most common infectious causes of diarrhea in SOT patients 6,7 . Immunosuppressive medication, especially mycophenolate, are common noninfectious causes of diarrhea 7–9 .…”

“…Clostridium difficile, norovirus, and cytomegalovirus (CMV) are the most common infectious causes of diarrhea in SOT patients. 6,7 Immunosuppressive medication, especially mycophenolate, are common noninfectious causes of diarrhea. [7][8][9] Other noninfectious causes include post-transplant lymphoproliferative disorder (PTLD), de novo inflammatory bowel disease (IBD), and graft versus host, the last being very rare in cases other than intestinal transplantation.…”

“…6,7 Immunosuppressive medication, especially mycophenolate, are common noninfectious causes of diarrhea. [7][8][9] Other noninfectious causes include post-transplant lymphoproliferative disorder (PTLD), de novo inflammatory bowel disease (IBD), and graft versus host, the last being very rare in cases other than intestinal transplantation. 6 The first step in diagnosing diarrhea among SOT patients is the microbiological testing for different infectious pathogens, especially among acute cases.…”